Piecemeal Resection Research Articles

Second-look surgery for pineal region tumors.

Surgical resection of pineal region tumors is challenging because of close proximity to the vein of Galen draining system and the quadrigeminal plate. Surgical resection usually is performed through the narrow corridor by piecemeal resection and en bloc resection is difficult in cases of large tumors. Moreover, in cases of hypervascular tumors, surgical resection through the narrow corridor could entail massive intraoperative bleeding. The effectiveness of neoadjuvant chemotherapy and second-look surgery for pineal region tumors for maximal safe resection was evaluated. Retrospective institutional review of pediatric patients with pineal region tumors who underwent second look surgery after neoadjuvant chemotherapy was performed. Nine patients underwent surgical resection after neoadjuvant chemotherapy over the period of September 2017 to February 2022. The mean age was 7.7years (ranged from 1.4 to 15.3years). Three patients underwent partial resection via open craniotomy, and 6 underwent endoscopic biopsy as an initial surgery. The histopathological diagnoses were germ cell tumors in 5 patients (yolk sac tumors in 2, germinoma in 2, choriocarcinoma in 1), /rhabdoid tumor (AT/RT) in 2, medulloblastoma in 1, and high-grade glioneuronal tumor in 1. After several courses of chemotherapy, the second-look surgery was performed. The tumor volume was reduced in 8 patients (89%) after chemotherapy except for 1 case of growing teratoma syndrome. The tumor was extended laterally to the ambient cistern in 2 patients, and posteriorly to the tentorial surface of the cerebellum in 3 patients. The lesion was approached through occipital transtentorial approach in 8 patients and infratentorial supracerebellar approach in 1. Intraoperatively, the high vascularity of the tumor was not observed in all cases. Gross total resection (8 patients, 89%) or near total resection (1, 11%) was achieved in all cases. No complications were observed postoperatively in all cases. Eight patients subsequently underwent additional chemo-radiation therapy according to the initial diagnosis. All patients are alive with no evidence of recurrence with a mean follow-up of 33months. Neoadjuvant chemotherapy and second-look surgery for pediatric pineal region tumors was considered to be effective in reducing the tumor volume and vascularity, which facilitates the safe maximal tumor resection.

S161 Cold Snare Endoscopic Mucosal Resection for Colon Polyps: A Systematic Review and Meta-Analysis

Introduction: Cold snare endoscopic mucosal resection (CS-EMR) has become increasingly popular for the removal of colon polyps > 10 mm. CS-EMR can potentially avert some of the risks associated with the use of electrocautery during polyp resection without compromising clinical efficacy. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of CS-EMR in removing colon polyps. Methods: We conducted a comprehensive literature search of MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov, and Scopus databases for studies published in the English language addressing outcomes of CS-EMR for colon polyps from database inceptions through April 2022. The weighted pooled estimates with the 95% confidence interval (CI) were calculated. Cochran Q test and I2 statistics were used to evaluate heterogeneity. Results: We identified 3599 articles on the initial search, and 32 full-text studies were assessed for eligibility. Fifteen studies met inclusion criteria. There were three randomized controlled trials, six prospective, and six retrospective studies. Six studies were from the United States, two each from Australia, China, and Japan, one from the United Kingdom, and one from Greece. A total of 2382 polyps were removed from 1756 patients. 45% were females. Polyps ranged from 6-80 mm in size, and 72.4% were proximal to the splenic flexure. In addition, 50.4% of the polyps were NICE I or serrated lesions and 48.5% were NICE II, and 0.1% were NICE III. Polyp recurrence rate after CS-EMR was 9.4 % (95% CI: 3.3-15.6%, I2= 95.8%), piecemeal resection rate 59.4% (95% CI: 46.3-72.4%, I2= 99.9%), and complete histological resection rate (defined by post polypectomy biopsies) was 93.1% (95% CI: 88.7-97.6%, I2=90.8%). For adverse events, delayed post-polypectomy bleeding rate was 0.8% (95% CI: 0.3-1.3%, I2= 21.4%), perforation and the post-polypectomy syndrome rate was 0.3% (95% CI: 0-0.5%, I2= 0%) (Figure). Given significant heterogeneity in recurrence rate, subgroup analyses were performed. Recurrence rate in serrated lesions (n=484) was 3.8% (95% CI: 0.2-7.4%, I2= 76.7%), in polyps < 20 mm (n= 137) 0.8% (95% CI: -0.7-2.3%, I2= 0%), and in polyps ≥ 20 mm (n=617) 15.7% (95% CI: 2.6-28.7%, I2= 95.2%). Conclusion: CS-EMR has an excellent safety profile and acceptable recurrence rate for resection of colon polyps, especially for polyps < 20 mm and serrated lesions. However, large prospective studies to validate safety and efficacy are needed.Figure 1.: Forest plots of A) recurrence rate, B) complete histological resection, C) delayed post polypectomy bleeding, and D) perforation of cold snare endoscopic mucosal resection in colon polyps

S1104 Endoscopic Papillectomy of Ampullary Lesions: Predictors of Recurrence and Adverse Events

Introduction: Endoscopic papillectomy (EP) is an effective endoscopic modality for managing ampullary adenomas, early ampullary carcinoma, and piecemeal resection of large laterally spreading lesions. EP has comparable efficacy and a better safety profile compared to a pancreaticoduodenectomy (Whipple surgery) or transduodenal ampullectomy (TA). However, there is a need to identify risk factors for recurrence and adverse events after EP. Thus, this study aims to evaluate predictors for recurrence and adverse events in patients who underwent EP for ampullary lesions. Methods: This study is a retrospective analysis of all consecutive patients who underwent endoscopic snare papillectomy for an ampullary lesion between January 2006 and December 2021. We assessed multiple patient and procedure-related variables to identify risk factors related to post-EP adverse events and ampullary lesion recurrence using both univariate and multivariate analysis. Results: A total of 51 patients undergoing EP for ampullary lesions were included in the final analysis. There were 11 patients with familial adenomatous polyposis (FAP) while 40 had sporadic lesions (Table). Recurrence was seen in 17 patients (37.0%) among those who followed up after technical success; five FAP (55.5%) and twelve sporadic (32.4%) patients had a recurrence. Adverse events included intraprocedural bleeding in 17 patients (33.3%), delayed bleeding requiring endoscopic evaluation in 7 patients (13.7%), post-ERCP pancreatitis (PEP) in 7 patients (13.7%), papillary stenosis in two patients (3.9%), and perforation in one (2%). Three patients (5.9%) had concomitant delayed bleeding and post-ERCP pancreatitis. Nine patients (19.6%) had intraprocedural bleeding requiring endoscopic clip placement of whom one later presented for delayed bleed. Age, method of resection, lesion size, and intraductal extensions were not associated with recurrence. Complete histologic (R0) resection was the only factor associated with no recurrence following EP (OR=5.4, 95% CI: 1.4-20.8, P-value=0.014). Post-ERCP pancreatitis was associated with delayed bleeding (OR=7.5, 95% CI: 1.2-46.1, P-value=0.03). The median follow-up was 228 (40-795) days for those who followed up (46 patients). Conclusion: In patients who underwent EP for ampullary lesions, R0 resection was associated with reduced risk of recurrence. In addition, delayed bleeding after EP is associated with an increased risk of developing PEP. Table 1. - Baseline characteristics of patients who underwent endoscopic papillectomy Characteristics (n=51) Age, years (median (IQR)) 65 (56-76) Gender (male) 29 (56.8%) Symptoms attributable to the ampullary lesion prior to EPAbdominal pain or dyspepsiaObstructive jaundicePancreatitisNone 8 (15.7%)7 (13.7%)4 (7.8%)32 (62.7%) Histology obtained prior to EP 40 (78.4%) Endoscopic ultrasound prior to EP 37 (72.5%) Lesion size, mm (median (IQR)) 15 (10.8-20) Median duration of the procedure in minutes (median (IQR)) 79 (57.8-101.3) Method of resection En-bloc snare resectionEn-bloc snare resection + APCPiecemeal snare resection Piecemeal snare resection + APC 30 (58.8%)8 (7.8%)6 (11.8%)7 (13.7%) Intraductal extension 8 (15.7%) Duodenal diverticulum 4 (7.8%) Altered post-surgical anatomy 3 (5.9%) Pancreas divisum 3 (5.9%) Biliary sphincterotomy 40 (78.4%) Pancreatic sphincterotomy 11 (21.6%) Submucosal lifting prior to EP 7 (13.7%) Pancreatic stent after EP 46 (90.2%) Biliary stent after EP 45 (88.2%) Final diagnosis Tubular adenomaTubulovillous adenoma Tubular adenoma with high grade dysplasiaAdenocarcinomaNeuroendocrine tumorsOther (non-neoplastic) 25 (49.0%)14 (27.5%)5 (9.8%)2 (3.9%)1 (2.0%)4 (7.8%) Concordant histology before and after EP 32 (62.7%) Complete histological (R0) resection 23 (45.1%) Number of procedures to achieve technical successOneTwoThree 44 (86.3%)5 (9.8%)2 (3.9%) Antiplatelets or anticoagulation therapy prior to EP 14 (27.5%) Overnight admission after EP 24 (47.1%) ED visit within 30 days of index EP 7 (13.7%) Hospital readmission within 30 days of index EP 6 (11.8%) APC: Argon plasma coagulation; ED: Emergency department; EP: Endoscopic papillectomy; IQR: Interquartile range.

Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction.

BACKGROUNDEndoscopic resection approaches, including endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR), have been widely used for the treatment of submucosal tumors (SMTs) located in the upper gastrointestinal tract. However, compared to SMTs located in the esophagus or stomach, endoscopic resection of SMTs from the esophagogastric junction (EGJ) is much more difficult because of the sharp angle and narrow lumen of the EGJ. SMTs originating from the muscularis propria (MP) in the EGJ, especially those that grow extraluminally and adhere closely to the serosa, make endoscopic resection even more difficult.AIMTo investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.METHODSA total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study. The difficulty of endoscopic resection was defined as a long procedure time, failure of en bloc resection and intraoperative bleeding. Clinicopathological, endoscopic and follow-up data were collected and analyzed. Statistical analysis of independent risks for piecemeal resection, long operative time, and intraoperative bleeding were assessed using univariate and multivariate analyses.RESULTSAccording to the location and growth pattern of the tumor, 44 patients underwent STER, 14 patients underwent EFTR, and the remaining 32 patients received a standard ESD procedure. The tumor size was 20.0 mm (range 5.0–100.0 mm). Fourty-seven out of 90 lesions (52.2%) were regularly shaped. The overall en bloc resection rate was 84.4%. The operation time was 43 min (range 16–126 min). The intraoperative bleeding rate was 18.9%. There were no adverse events that required therapeutic intervention during or after the procedures. The surgical approach had no significant correlation with en bloc resection, long operative time or intraoperative bleeding. Large tumor size (≥ 30 mm) and irregular tumor shape were independent predictors for piecemeal resection (OR: 7.346, P = 0.032 and OR: 18.004, P = 0.029, respectively), long operative time (≥ 60 min) (OR: 47.330, P = 0.000 and OR: 6.863, P = 0.034, respectively) and intraoperative bleeding (OR: 20.631, P = 0.002 and OR: 19.020, P = 0.021, respectively).CONCLUSIONEndoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ. Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.

Neoadjuvant Stereotactic Radiotherapy for Brain Metastases: Systematic Review and Meta-Analysis of the Literature and Ongoing Clinical Trials.

Simple SummaryThe available treatment strategies for patients with brain metastases remain suboptimal, with current research focused on identifying therapies intended to improve patient outcomes while reducing the risk of treatment-related complications. Several studies have investigated the role of pre-operative neoadjuvant stereotactic radiotherapy, and have proposed it as a valid alternative to post-operative adjuvant stereotactic radiotherapy. The aim of our systematic review was to comprehensively analyze the current literature and ongoing clinical trials evaluating neoadjuvant stereotactic radiotherapy in patients with brain metastases, describing treatment protocols and related outcomes. Early evidence suggests that neoadjuvant stereotactic radiotherapy may offer rates of local control and overall survival comparable to those obtained with adjuvant postoperative SRS, but comparative studies are currently lacking. In addition, neoadjuvant stereotactic radiotherapy shows low rates of post-treatment radiation necrosis and leptomeningeal metastases. Ongoing clinical trials aim to evaluate long-term outcomes in large patient cohorts, with some focused on comparing neoadjuvant stereotactic radiotherapy to adjuvant stereotactic radiosurgery.Background: Brain metastases (BMs) carry a high morbidity and mortality burden. Neoadjuvant stereotactic radiotherapy (NaSRT) has shown promising results. We systematically reviewed the literature on NaSRT for BMs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, Cochrane, and ClinicalTrial.gov were searched following the PRISMA guidelines to include studies and ongoing trials reporting NaSRT for BMs. Indications, protocols, and outcomes were analyzed using indirect random-effect meta-analyses. Results: We included 7 studies comprising 460 patients with 483 BMs, and 13 ongoing trials. Most BMs originated from non-small lung cell carcinoma (41.4%), breast cancer (18.7%) and melanoma (43.6%). Most patients had single-BM (69.8%) located supratentorial (77.8%). Patients were eligible if they had histologically-proven primary tumors and ≤4 synchronous BMs candidate for non-urgent surgery and radiation. Patients with primary tumors clinically responsive to radiotherapy, prior brain radiation, and leptomeningeal metastases were deemed non-eligible. Median planning target volume was 9.9 cm3 (range, 2.9–57.1), and NaSRT was delivered in 1-fraction (90.9%), 5-fraction (4.8%), or 3-fraction (4.3%), with a median biological effective dose of 39.6 Gy10 (range, 35.7–60). Most patients received piecemeal (76.3%) and gross-total (94%) resection after a median of 1-day (range, 1–10) post-NaSRT. Median follow-up was 19.2-months (range, 1–41.3). Actuarial post-treatment rates were 4% (95%CI: 2–6%) for symptomatic radiation necrosis, 15% (95%CI: 12–18%) and 47% (95%CI: 42–52%) for local and distant recurrences, 6% (95%CI: 3–8%) for leptomeningeal metastases, 81% (95%CI: 75–87%) and 59% (95%CI: 54–63%) for 1-year local tumor control and overall survival. Conclusion: NaSRT is effective and safe for BMs. Ongoing trials will provide high-level evidence on long-term post-treatment outcomes, further compared to adjuvant stereotactic radiotherapy.

Multipolar traction with adjustable force increases procedure speed during endoscopic submucosal dissection: the A-TRACT-4 traction device.

A major barrier to the more widespread use of endoscopic submucosal dissection (ESD) remains the long-lasting duration of the procedure compared to piecemeal endoscopic mucosal resection (EMR). Several devices and techniques have been described to speed and ease the procedure [1], and traction strategies are implemented more and more to improve efficiency of the dissection phase.

Hemothorax due to a ruptured esophageal gastrointestinal stromal tumor: case report

BackgroundEsophageal gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal interstitium, and comprise less than 0.7% of all GISTs. The presentation of esophageal GIST is relatively benign, commonly characterized by symptoms of dysphagia and gastrointestinal bleed. On the contrary, it is highly unusual for these tumors to present as surgical emergencies.Case presentationHere, we describe a case of hemothorax secondary to the rupture of a massive (19 cm) esophageal GIST in a 79-year-old male. The patient presented with mild back pain, vomiting, and hypotension. A CT scan revealed significant mediastinal enlargement and left hemothorax. We conducted an emergency thoracotomy which revealed a 19 × 15 × 7 cm ruptured esophageal tumor that was bleeding profusely into the left thoracic cavity. Piecemeal resection without esophagectomy was performed to achieve hemostasis. Pathological evaluation of resected tissue confirmed the diagnosis of GIST. The patient was provided adjuvant imatinib therapy and remains progression-free at the 10-month follow-up.ConclusionsTo the best of our knowledge, this is the first reported case of life-threatening hemothorax caused by a ruptured esophageal GIST. Findings from this case may aid in the diagnosis and management of these rare tumors.

Prospective single-center feasible study of innovative autorelease bile duct supporter to delay adverse events after endoscopic papillectomy.

BACKGROUNDConventional endoscopic papillectomy (EP) is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions. As reported by some existing studies, temporarily placing a prophylactic stent in the pancreatic and bile duct can lower the risk of this perioperative complication.AIMTo evaluate the usefulness, convenience, safety, and short-term results of a novel autorelease bile duct supporter after EP procedure, especially the effectiveness in preventing EP.METHODSA single-center comparison study was conducted to verify the feasibility of the novel method. After EP, a metallic endoclip and human fibrin sealant kit were applied for protection. The autorelease bile duct supporter fell into the duct segment and the intestinal segment. Specifically, the intestinal segment was extended by nearly 5 cm as a bent coil. The bile was isolated from the pancreatic juice using an autorelease bile duct supporter, which protected the wound surface. The autorelease bile duct supporter fell off naturally and arrived in colon nearly 10 d after the operation.RESULTS En bloc endoscopic resection was performed in 6/8 patients (75%), and piecemeal resection was performed in 2/8 of patients (25%). None of the above patients were positive for neoplastic lymph nodes or distant metastasis. No cases of mortality, hemorrhage, delayed perforation, pancreatitis, cholangitis or duct stenosis with the conventional medical treatment were reported. The autorelease bile duct supporter in 7 of 8 patients fell off naturally and arrived in colon 10 d after the operation. One autorelease bile duct supporter was successfully removed using forceps or snare under endoscopy. No recurrence was identified during the 8-mo (ranging from 6-9 mo) follow-up period.CONCLUSIONIn brief, it was found that the autorelease bile duct supporter could decrease the frequency of procedure-associated complications without second endoscopic retraction. Secure closure of the resection wound with clips and fibrin glue were indicated to be promising and important for the use of autorelease bile duct supporters. Well-designed larger-scale comparative studies are required to confirm the findings of this study.

CLRM-20 IDENTIFYING RISK FACTORS AND ANALYZING SURVIVAL FOLLOWING PACHYMENINGEAL FAILURE

OBJECTIVENeurosurgery (NS) is an essential modality for large brain metastases (BM). As an adjuvant treatment, stereotactic radiosurgery (SRS) reduces neurocognitive toxicity without affecting post-treatment overall survival (OS) compared to whole brain radiation therapy. Pachymeningeal failure (PMF) beyond the SRS field is a relatively newly described entity, distinct from classical leptomeningeal failure (LMF), and unique to postoperative patients treated with adjuvant SRS. We sought to identify risk factors for PMF in patients treated with NS+SRS. METHODSWe reviewed a prospective registry (2009 to 2020) and identified all patients treated with NS+SRS. Clinical, radiological, pathological and treatment factors were analyzed. PMF incidence was evaluated using a competing risks model and differences between cohorts were measured using the Fine-Gray method. RESULTS144 Patients were identified. Median age was 62 (23-90). PMF occurred in 22.2% (32/144) patients). Univariate analysis indicated female gender (HR 2.65, p=0.013), higher GPA status (HR 2.4, p<0.001), absence of prior radiation therapy (HR N/A, p=0.018), controlled extracranial disease (CED) (HR 3.46, p=0.0038), and contact with the pia/dura (HR 3.30, p=0.0053) as risk factors for PMF. Piecemeal (vs En-bloc) resection also trended towards correlation (HR 2.07, p=0.054). Multivariate Analysis identified contact with pia/dura (HR 3.51, p=0.0053), piecemeal resection (HR 2.38, p=0.027), and CED (HR 3.97, p=0.0016) as significant correlates to PMF. PMF correlated with reduced OS (HR 2.90, p<0.001) but was improved compared to patients who developed LMF (HR 10.15, p= p<0.001). CONCLUSIONSPMF is an underrecognized phenomenon that correlates with pre-operative pia/dura contact and piecemeal resection in patients treated with NS+SRS for BM. While less morbid than LMF, it is a critical event that deserves increased vigilance and analysis.

Long-term Outcomes After Endoscopic Submucosal Dissection for Large Colorectal Epithelial Neoplasms: A Prospective, Multicenter, Cohort Trial From Japan

To determine the long-term outcomes after colorectal endoscopic submucosal dissection (ESD), we conducted a large, multicenter, prospective cohort trial with a 5-year observation period. Between February 2013 and January 2015, we consecutively enrolled 1740 patients with 1814 colorectal epithelial neoplasms ≥20 mm who underwent ESD. Patients with noncurative resection (non-CR) lesions underwent additional radical surgery, as needed. After the initial treatment, intensive 5-year follow-up with planned multiple colonoscopies was conducted to identify metastatic and/or local recurrences. Primary outcomes were overall survival, disease-specific survival, and intestinal preservation rates. The rates of local recurrence and metachronous invasive cancer were evaluated as the secondary outcomes. The 5-year overall survival, disease-specific survival, and intestinal preservation rates were 93.6%, 99.6%, and 88.6%, respectively. Patients with CR lesions had no metastatic occurrence, and patients with non-CR lesions had 4 metastatic occurrences. Kaplan-Meier curves revealed that overall survival and disease-specific survival rates were significantly higher in patients with CR lesions than in those with non-CR lesions (P > .001 and P= .009, respectively). Local recurrence occurred in only 8 lesions (0.5%), which were successfully resected by subsequent endoscopic treatment. Multiple logistic regression analyses revealed that piecemeal resection (hazard ratio, 8.19; 95% CI, 1.47-45.7; P= .02) and margin-positive resection (hazard ratio, 8.06; 95% CI, 1.76-37.0; P= .007) were significant independent predictors of local recurrence after colorectal ESD. Fifteen metachronous invasive cancers (1.0%) were identified during surveillance colonoscopy, most of which required surgical resection. A favorable long-term prognosis indicates that ESD can be the standard treatment for large colorectal epithelial neoplasms. UMIN000010136.

Surgical Management of a Massive Frontal Bone Hemangioma: Case Report.

Intraosseous hemangiomas are rare, benign tumors that can arise from the calvarium. These lesions often invade the outer table of the skull, but typically spare the inner table and intracranial structures. En bloc surgical resection is the standard treatment for intraosseous hemangiomas. However, a piecemeal resection may be required to safely remove the tumor in cases involving the inner table to protect the underlying brain parenchyma and vascular structures. Proper reconstruction is critical to optimize the cosmetic outcome, and a staged procedure allowing implantation of a custom-made implant can be considered for large lesions involving the forehead. We present a case of a patient with a large frontal intraosseous hemangioma with intradural involvement to highlight the surgical nuances of resection and review the existing literature regarding optimal management of these patients.

Factors predicting occurrence and therapeutic choice in malignant colorectal polyps: a study of 13 years of colonoscopic polypectomy.

Colorectal carcinoma represents a major cause of mortality and 0.2–12% of resected colonic polyps have malignant cells inside. We performed a retrospective study of patients with resected polyps during a period of 13 years. A total of 905 patients had 2033 polyps removed; 122 polyps (109 patients) had malignant cells. Prevalence of malignant polyps with submucosal invasion was 1.23% and for all polyps with malignant cells was 6%; malignant polyps had a larger size (23.44 mm mean diameter) vs benign polyps (9.63 mm); the risk of malignancy was increased in polyps larger than 10 mm, in lateral spreading lesions and in Paris types 0-Ip, 0-Isp, in sigmoid, descending colon and rectum, in sessile serrated adenoma and traditional serrate adenoma subtypes of serrated lesions and in tubulovillous and villous adenoma. In 18 cases surgery was performed, in 62 patients only colonoscopic follow-up was made and in 35 patients no colonoscopic follow-up was recorded. From initially endoscopic resected polyps, recurrence was noted in seven (11.3%) cases; there was a trend toward association with depth of invasion, piecemeal resection, right and rectum location, sessile and lateral spreading type and pathological subtype. In surgical group, post-therapeutic staging was available in 11 cases; nodal involvement was noted in three (27.27%) cases; none had lymphatic or vascular invasion in endoscopically resected polyps. Four patients with no macroscopic local recurrence underwent surgery with no residual tumor. The rate of metastasis was 16.67% in surgical group and 1.61% in endoscopic group. Evaluation of lymph node (LN) invasion was available for 11 operated patients, with LN invasion (N1) in three patients, local residual tumoral tissue in one patient with incomplete resection and no residual tumor (R0 resection) in four patients with endoscopic resection before surgery.

Endoscopic submucosal dissection or piecemeal endoscopic mucosal resection for large superficial colorectal lesions: A cost effectiveness study

Background and aimsEndoscopic management is preferred to surgical management for large superficial colorectal lesions. However, the optimal endoscopic resection strategy (piecemeal endoscopic mucosal resection [pEMR] or endoscopic submucosal dissection [ESD]) is still debated from an economical point of view. To date, in France, there is no Health Insurance reimbursement rate for the hospital stays related to ESD. We searched to estimate the global cost of colorectal ESD and to define the most cost-effectiveness endoscopic strategy. MethodsA model was created to compare the cost-effectiveness of ESD and pEMR according to optical diagnosis (Japan NBI Expert Team [JNET], laterally spreading tumour [LST], CONECCT). We distinguished three groups from the same multicentre ESD cohort and compared the medical and economic outcomes: real-life ESD data (Universal-ESD or U-ESD) compared to modelled selective ESD (S-ESD JNET; S-ESD LST; S-ESD CONECCT) and exclusive pEMR strategies (Universal-EMR or U-EMR). ResultsThe en-bloc, R0, and curative resection rates were 97.5%, 86.5%, and 82.6%, respectively in the real life French ESD cohort of 833 colorectal lesions. U-ESD was the least-expensive strategy, with a global cost of 2,858,048.17 €, i.e. 3,431.03 €/patient and was also the most effective strategy because it avoided 774 surgeries, which was more than any other strategy. It outperformed S-ESD CONNECT (global cost = 2,951,411.44 €, and 3,543.11 €/patient, 765 surgeries avoided, S-ESD LST (global cost = 3,055,951.53 €, and 3,668.61 €/patient, 749 surgeries avoided), and S-ESD JNET (global cost = 3,547,426.97 € and 4,258.62 €/patient, 704 surgeries avoided) and U-EMR (global cost = 4,060,547.62 € and 4,874.61 €/patient, 620 surgeries avoided). Even though a model which optimized pEMR results (0% technical failure, 0% primary surgery), U-EMR strategy remained the most expansive strategy and the one that avoided the least surgeries. ConclusionESD for all LSTs upper than 20 mm is more cost-effective than pEMR, and S-ESD.

En Bloc Resection of Bladder Tumor May be the best choice?

The quality of transurethral tumor resection plays an important role in histopathological assessment and treatment decision-making, which affects the prognosis of the disease. Piecemeal resection of tumor tissue leads to the dissemination

Factors for conversion risk of colorectal endoscopic submucosal dissection: a multicenter study.

Endoscopic submucosal dissection (ESD) has become a widely accepted treatment method for colorectal tumors; however, there are some persistent problems. This multi-center study aimed to characterize the risk factors for incomplete resection and perforation in standardized colorectal ESD procedures. This study included 2423 consecutive patients who underwent ESD for 2592 colorectal tumors between August 2013 and December 2018 at 11 institutions (1 academic hospital and 10 affiliated hospitals) from the Hiroshima GI Endoscopy Research Group. We evaluated the risk factors for interruption, piecemeal resection, and perforation of standardized colorectal ESD in relation to clinicopathologic and endoscopic characteristics. The incidences of interruption, piecemeal resection, and perforation were 0.7%, 2.9%, and 3.0%, respectively. Multivariate analysis identified the following risk factors for interruption: perforation during the procedure, deep submucosal invasion (> 1000μm), poor scope operability, and severe submucosal fibrosis. The risk factors for piecemeal resection included poor scope operability, severe submucosal fibrosis, and procedure time (≥ 85min). The risk factors for perforation during the procedure were severe submucosal fibrosis, poor scope operability, procedure time (≥ 85min), and tumor size (≥ 40mm). Independent risk factors for severe submucosal fibrosis included a history of biopsy and lesions located on the fold or flexure. Severe submucosal fibrosis and poor scope operability are the common risk factors for interruption, piecemeal resection, and perforation in standardized colorectal ESD.

Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study.

BACKGROUNDAmpullary adenoma is a rare premalignant lesion, but its incidence is increasing. Endoscopic papillectomy has become the first treatment of choice for ampullary adenomas due to its safety and effectiveness, thereby replacing surgical resection. However, recurrence rates and adverse events after endoscopic papillectomy were reported in up to 30% of cases.AIMTo review the long-term outcomes of endoscopic papillectomy and investigate the factors that affect these outcomes.METHODSWe retrospectively analyzed the data of patients who underwent endoscopic papillectomy for ampullary adenoma at five tertiary hospitals between 2013 and 2020. We evaluated clinical outcomes and their risk factors. The definitions of outcomes were as follow: (1) curative resection: complete endoscopic resection without recurrence; (2) endoscopic success: treatment of ampullary adenoma with endoscopy without surgical intervention; (3) early recurrence: reconfirmed adenoma at the first endoscopic surveillance; and (4) late recurrence: reconfirmed adenoma after the first endoscopic surveillance.RESULTSA total of 106 patients were included for analysis. Of the included patients, 81 (76.4%) underwent curative resection, 99 (93.4%) had endoscopic success, showing that most patients with non-curative resection were successfully managed with endoscopy. Sixteen patients (15.1%) had piecemeal resection, 22 patients (20.8%) had shown positive/uncertain resection margin, 11 patients (16.1%) had an early recurrence, 13 patients (10.4%) had a late recurrence, and 6 patients (5.7%) had a re-recurrence. In multivariate analysis, a positive/uncertain margin [Odds ratio (OR) = 4.023, P = 0.048] and piecemeal resection (OR = 6.610, P = 0.005) were significant risk factors for early and late recurrence, respectively. Piecemeal resection was also a significant risk factor for non-curative resection (OR = 5.424, P = 0.007). Twenty-six patients experienced adverse events (24.5%).CONCLUSIONEndoscopic papillectomy is a safe and effective treatment for ampullary adenomas. Careful selection and follow-up of patients is mandatory, particularly in cases with positive/uncertain margin and piecemeal resection.

A Rectum-Specific Selective Resection Algorithm Optimizes Oncologic Outcomes for Large Nonpedunculated Rectal Polyps

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are complementary techniques for large (≥20 mm) nonpedunculated rectal polyps (LNPRPs). A mechanism for appropriate technique selection has not been described. We evaluated the performance of a selective resection algorithm (SRA) (August 2017 to April 2021) compared with a universal EMR algorithm (UEA) (July 2008 to July 2017) for LNPRPs within a prospective observational study. In the SRA, LNPRPs with features of superficial submucosal invasive cancer (SMIC) (<1000 μm; Kudo pit pattern Vi), or with an increased risk of SMIC (Paris 0-Is or 0-IIa+Is nongranular, 0-IIa+Is granular with a dominant nodule ≥10 mm) underwent ESD. The remaining LNPRPs underwent EMR. Algorithm performance was evaluated by SMIC identified after EMR, curative oncologic resection (R0 resection, superficial SMIC, absence of negative histologic features), technical success, adverse events, and recurrence at first surveillance colonoscopy. A total of 480 LNPRPs were evaluated (290 UEA, 190 SRA). Median lesion size was 40 (interquartile range, 30-60) mm. SMIC was identified in 56 (11.7%) LNPRPs. Significant differences in SMIC after EMR (SRA 1 [1.0%] vs UEA 35 [12.1%]; P= .001) and curative oncologic resection (SRA n= 7 [33.3%] vs UEA n= 2 [5.7%]; P= .010) were identified. No significant differences in technical success or adverse events were identified (all P > .137). Among LNPRPs with SMIC amenable to curative oncologic resection and which underwent ESD, 100% (n= 7 of 7) were cured. A rectum-specific SRA optimizes oncologic outcomes for LNPRPs and mitigates the risk of piecemeal resection of cancers.

V09-01 THULIUM FIBER LASER EN BLOC RESECTION FOR BLADDER TUMOUR. TIPS AND TRICKS

You have accessJournal of UrologyCME1 May 2022V09-01 THULIUM FIBER LASER EN BLOC RESECTION FOR BLADDER TUMOUR. TIPS AND TRICKS Dmitry Enikeev, Andrey Morozov, Mark Taratkin, Diana Babaevskaya, Roman Sukhanov, and Petr Glybochko Dmitry EnikeevDmitry Enikeev More articles by this author , Andrey MorozovAndrey Morozov More articles by this author , Mark TaratkinMark Taratkin More articles by this author , Diana BabaevskayaDiana Babaevskaya More articles by this author , Roman SukhanovRoman Sukhanov More articles by this author , and Petr GlybochkoPetr Glybochko More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002617.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: According to a number of guidelines, en bloc resection of bladder tumor has been considered standard procedure since 2018 along with conventional transurethral resection with electric loop. It may improve grading and even oncological outcomes due to the presence of the muscle layer. Moreover, piecemeal resection may lead to tumor re-implantation and relapse due to long contact with the bladder walls. However, despite its advantages, en bloc resection is considered to be a more difficult procedure. With this video we want to share our experience with en bloc and provide data on its outcomes. METHODS: We provide outcomes of 71 consecutive en bloc resections of bladder tumor with thulium fiber laser in the Institute for Urology and Reproductive Health, Sechenov University. A comparison group consisted of 58 consecutive monopolar TURBTs. All the procedures were recorded. RESULTS: In the video we address different aspects of the en bloc technique and provide step-by-step guidance. We also offer advice on how to successfully perform en bloc in case of tumor larger than 3 cm, or tumor invading the ureteric orifice. At 6 months, recurrence was detected in 19 patients after TURBT and in 6 patients after Tm fiber en bloc, OR 6.1 (95% CI 1.6 – 23.8, p=0.009). Univariate analysis also showed association between muscle layer presence and relapse rate, OR 4.63 (95% CI 1.1 – 19.4, p=0.36). CONCLUSIONS: With the presented videos we intend to highlight that en bloc is no more difficult than TURBT and it is applicable in different cases including large tumors. We believe this will help surgeons to master this technique. Our data suggest that en bloc offers improved oncological outcomes. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e805 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Enikeev More articles by this author Andrey Morozov More articles by this author Mark Taratkin More articles by this author Diana Babaevskaya More articles by this author Roman Sukhanov More articles by this author Petr Glybochko More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP59-13 BLADDER TUMOR ACCURATE RADIOFREQUENCY RESECTION: 38 CASES REPORTS

You have accessJournal of UrologyCME1 May 2022MP59-13 BLADDER TUMOR ACCURATE RADIOFREQUENCY RESECTION: 38 CASES REPORTS Shengkun Sun, Guangfu Chen, Weijun Fu, and Xu Zhang Shengkun SunShengkun Sun More articles by this author , Guangfu ChenGuangfu Chen More articles by this author , Weijun FuWeijun Fu More articles by this author , and Xu ZhangXu Zhang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002642.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bladder cancer is the fourth most frequently diagnosed malignancy in males and the 12th most common malignancy in females. Transurethral resection of bladder tumor (TURBT) remains the mainstay of diagnosis and initial treatment of bladder neoplasms. TURBT is performed conventionally with an electrocautery loop. The piecemeal resection specimens are inappropriate for tumor pathological evaluation because of poor anatomic orientation and evaluation of the pathological depth is not necessarily accurate. Also, tumor cells are scattered as the tumor is fragmented so that the possibility of implantation cannot be excluded. The objective of this study is to optimize the surgical method of transurethral bladder tumor resection. METHODS: 38 patients with non-muscle invasive bladder cancer received transurethral accurate resection of the tumor with a novel β electrode with a radiofrequency energy platform. Normal bladder mucosa 0.5 to 1 cm from the tumor base was marked with the tip of β electrode with an electrocautery energy. The needle of the β electrode was insert into the submucosa, and tissue of the bladder wall was pulled towards the midline of the bladder, followed by electro-cutting. Tumor blood vessels were cauterized with the needle tip. After en bloc resection of the tumor bulk, a novel β basket, which could be opened and trapped the tumor in bladder, was introduced into the bladder to retrieve the tumor en bloc or sub-en bloc. RESULTS: Tumors exceeded T2 stage or tumors with a maximum diameter of less than 1 cm were excluded. 38 patients underwent accurate transurethral radiofrequency resection of bladder tumors, and a total of 47 tumors were removed. The maximum diameter of the tumor is 2.4cm (range from 1 to 5cm). Tumors less than 3cm could be retrieved through the resection sheath or be taken out with the β basket. 12 tumors with a maximum diameter of >3cm were divided into 2-3 large pieces by the β basket and then taken out. During the operation, there was no obturator nerve reflex, no bladder perforation or urine extravasation. The intraoperative bleeding was less than 2ml in every patient. The bladder was flushed with normal saline for 24 hours post operation. Postoperative pathology showed Ta in 27cases and T1 in 11 cases. No second TURBT was performed in this group. No operative complications occurred. All patients received intravesical irrigation of BCG or chemotherapy agent periodically. 2 patients had tumor recurrence in the bladder during the mean follow-up of 8.7 months (range from 3 to 11 months). CONCLUSIONS: A novel β electrode was used to remove the tumor during accurate transurethral radiofrequency resection of bladder tumors. There are several advantages of this novel method. First, the blood supply of the tumor was occluded to avoid bleeding. Second, the obturator nerve reflex could be prevented completely and local nerve blockage was not necessary. Third, accurate radiofrequency resection of bladder tumor improved the resection quality and the en bloc resection helped make accurate TNM stage which was significant for postoperative treatment strategy. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1007 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shengkun Sun More articles by this author Guangfu Chen More articles by this author Weijun Fu More articles by this author Xu Zhang More articles by this author Expand All Advertisement PDF DownloadLoading ...

Clinical outcomes of endoscopic resection of superficial nonampullary duodenal epithelial tumors: A 10-year retrospective, single-center study.

BACKGROUNDAlthough premalignant duodenal lesions such as adenomas are uncommon, the incidences of these lesions have increased in recent times, and thus, the demand for minimally invasive treatments such as endoscopic resection (ER) has also increased. However, ER in the duodenum is more challenging than ER in other locations of the gastrointestinal tract.AIMTo evaluate the safety and efficacy of ER for superficial nonampullary duodenal epithelial tumors (SNADETs)METHODSWe performed a retrospective observational study on 56 consecutive patients (58 lesions) diagnosed with SNADETs that underwent ER from January 2011 to December 2020 at Yeungnam University Hospital. Patient demographics, lesion characteristics, and procedural and technical data were collected, and clinical outcomes, including procedure-related complications, completeness of resection, and recurrence were analyzed.RESULTSMedian patient age was 57 years [range, 26–77, 30 (53.6%) men]. Endoscopic mucosal resection (EMR) was performed on 57 lesions (98.3%) and snare polypectomy on one (1.7%). Lesions consisted of 52 adenomas with low-grade dysplasia (89.7%), 3 adenomas with high-grade dysplasia (5.2%), and 3 intramucosal adenocarcinomas (5.2%). There were 16 cases of intraprocedural bleeding (27.6%) and 1 case of delayed bleeding (1.7%), and all these 17 cases were successfully managed endoscopically. No perforation or procedure-related death occurred. Larger lesion size was associated with an increased risk of EMR-related bleeding (P = 0.033). During a median follow-up period of 23 mo (range 6–100 mo), no local recurrence occurred, despite the fact one-third of the patients (19 lesions, 32.8%) underwent piecemeal resection and 3 patients (3 lesions, 5.2%) that underwent en bloc resection had a pathologically determined positive lateral margin. No patient died from a primary duodenal neoplasm. CONCLUSIONThe majority of SNADETs can be safely and curatively resected by EMR, and thus, based on consideration of the high incidence of fatal complications attributable to ESD, we conclude EMR, including piecemeal resection, should be considered the treatment of first choice for SNADETs.