Safety Of Endoscopic Submucosal Dissection Research Articles

Application of endoscopic submucosal dissection in duodenal space-occupying lesions.

BACKGROUNDEndoscopic submucosal dissection (ESD) has been advocated by digestive endoscopists because of its comparable therapeutic effect to surgery, reduced trauma, faster recovery, and fewer complications. However, ESD for lesions of the duodenum is more challenging than those occurring at other levels of the gastrointestinal tract due to the thin intestinal wall of the duodenum, narrow intestinal space, rich peripheral blood flow, proximity to vital organs, and high risks of critical adverse events including intraoperative and delayed bleeding and perforation. Because of the low prevalence of the disease and the high risks of severe adverse events, successful ESD for lesions of the duodenum has rarely been reported in recent years.AIMTo investigate the efficacy and safety of ESD in the treatment of duodenal space-occupying lesions.METHODSClinical data of 24 cases of duodenal lesions treated by ESD at the Digestive Endoscopy Center of the Affiliated Hospital of Qingdao University from January 2016 to December 2019 were retrospectively analyzed.RESULTSAll of the 24 cases from 23 patients underwent ESD treatment for duodenal space-occupying lesions under general anesthesia, including 15 male and 8 female patients, with a mean age of 58.5 (32.0-74.0) years. There were 12 lesions (50%) in the duodenal bulb, 9 (37.5%) in the descending part, and 3 (12.5%) in the ball-descending junction. The mean diameter of the lesion was 12.75 (range, 11-22) mm. Thirteen lesions originated from the mucosa, of which 4 were low-grade intraepithelial neoplasia, 3 were hyperplastic polyps, 2 were chronic mucositis, 2 were adenomatous hyperplasia, 1 was high-grade intraepithelial neoplasia, and 1 was tubular adenoma. Eleven lesions were in the submucosa, including 5 neuroendocrine neoplasms, 2 cases of ectopic pancreas, 1 stromal tumor, 1 leiomyoma, 1 submucosal duodenal adenoma, and 1 case of submucosal lymph follicular hyperplasia. The intraoperative perforation rate was 20.8% (5/24), including 4 submucosal protuberant lesions and 1 depressed lesion. The mean length of hospital stay was 5.7 (range, 3-10) d, and the average follow-up time was 25.8 (range, 3.0–50.0) mo. No residual disease or recurrence was found in all patients, and no complications, such as infection and stenosis, were found during the follow-up period.CONCLUSIONESD is safe and effective in the treatment of duodenal lesions; however, the endoscopists should pay more attention to the preoperative preparation, intraoperative skills, and postoperative treatment.

Efficacy and safety of a novel submucosal injection solution for endoscopic resection in porcine models.

A submucosal injection is usually required to improve the efficacy and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR). This study aimed to evaluate the performance of 3.3% sodium carboxymethyl starch (Na-CMS) solution, a novel submucosal injection solution, for ESD and EMR. Na-CMS, normal saline (NS) and two commercially available agents (sigMAVisc and Eleview) were injected into the esophageal submucosa of randomly grouped pigs. The level of submucosal elevation was examined. Subsequently, ESD or EMR procedures using 3.3% Na-CMS or NS as submucosal injections were performed in the gastrointestinal tract of the pigs. Submucosal elevation was significantly higher and more sustained in the 3.3% Na-CMS group than in the controls (P < 0.05). The volume required for ESD or EMR was significantly lower in the 3.3% Na-CMS group than in the NS group (ESD: 12.21 ± 4.09 mL vs 28.25 ± 8.02 mL, P < 0.001; EMR: 3.99 ± 1.98 mL vs 7.15 ± 3.67 mL, P = 0.001). The ESD resection time was significantly shorter in the 3.3% Na-CMS group than in the NS group (16.58 ± 7.30 min vs 25.29 ± 11.89 min, P = 0.004). Hemorrhage after ESD in the 3.3% Na-CMS group was less severe than that in the NS group (P = 0.006). 3.3% Na-CMS is an effective, safe and low-cost submucosal injection solution and holds promise as preferable agent for submucosal injection in ESD and EMR procedures.

Rectal neoplasia extending to the dentate line: clinical outcomes of endoscopic submucosal dissection

Background The European Society of Gastrointestinal Endoscopy (ESGE) and the Japan Gastroenterological Endoscopy Society (JGES) give no specific recommendations on the best treatment for colorectal neoplasia involving the dental line (DLCN). Objective Aim of this study was to analyse efficacy and safety of Endoscopic Submucosal Dissection in the treatment of colorectal neoplasia involving the dentate line (DLCN) compared to non-DLCN. Design Retrospective study. Patients We retrospectively evaluated all consecutive patients undergoing ESD for rectal neoplasia at two endoscopical tertiary referral centers (Italy and Japan) from January 2008 to December 2019. Main outcome measures Anthropometric, clinical, procedural, and follow-up data was collected, analysed, and compared between patients with DLCN and patients with non-DLCN. Results Overall, 314 patients were enrolled (163 female, 51.9%). Mean age was 68 years (range, 32–92 years). En-bloc resection was achieved in 311/314 (99%) patients. Lesion size was higher in DLCN group than in the non-DLCN group (46.1 vs 38.9 mm; p = .03). Submucosal invasion rate was also higher in the DLCN group (29.6 vs 18.4%, p = .04). Procedure time was significantly longer in the DLCN group, (89.6 vs. 73.1 min; p = .002). Hospitalization length following ESD was similar in both groups. Limitations Retrospective study design. Conclusions ESD seems to be safe and effective in the treatment of colorectal neoplasia involving the dentate line and can be considered the best therapeutic strategy.

S0903 Efficacy and Safety of Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection in Barrett’s Esophagus-Related Early Neoplasia: A Systematic Review and Pooled Comparative Analysis

INTRODUCTION: Focal endoscopic mucosal resection (EMR) followed by radiofrequency ablation (EMR + RFA) and stepwise/complete EMR (s-EMR) have been used for management of Barrett’s esophagus related high grade dysplasia (HGD) and early adenocarcinoma (EAC). Recently, endoscopic submucosal dissection (ESD) has been utilized with good efficacy. A systematic review and meta-analysis to evaluate the cumulative & comparative efficacy and safety of different endoscopic therapies. METHODS: We searched several databases from inception through April 2020 for studies evaluating efficacy and safety of ESD, EMR + RFA and sEMR for management of Barrett’s related early neoplasia. Our primary outcomes of interest were recurrence of HGD or EAC, along with risk of strictures, perforation and bleeding. Secondary outcomes included enbloc and R0 resections for ESD, complete eradication of neoplasia for EMR-RFA and sEMR. Weighted pooled rates (WPR) were calculated for each outcome. Proportionate difference was calculated to compare different endoscopic modalities in terms of primary outcomes of interest. RESULTS: A total of 37 studies [14 ESD, 12 EMR + RFA, 11 sEMR], with 2377 patients [682 ESD, 872 EMR + RFA, 823 sEMR] were included in this systematic review and meta-analysis. 82.4% patients were males. WPR for recurrence with ESD, EMR + RFA and sEMR were 10.3% (6.6%, 15.8%), 5% (2.3%, 10%) & 7.4% (4.6%, 12%), respectively. No difference in recurrence with any endoscopic modality (P > 0.05). WPR for strictures during follow up with ESD, EMR + RFA & sEMR were 9.5% (3.6%, 23%), 11.5% (7.3%, 17.8%) & 29% (21%, 38%), respectively. ESD and EMR + RFA were associated with lower stricture formation as compared to sEMR (P < 0.05), while no difference in stricture formation between ESD and EMR + RFA. WPR for perforation with ESD, EMR + RFA and sEMR were 3.7% (2.2%, 6%), 1.6% (0.6%, 3.3%) & 2% (1%, 3.5%), respectively. EMR + RFA was associated with lower risk of perforation as compared to ESD (P = 0.01), while no difference in perforation risk between ESD and sEMR. WPR for bleeding with ESD, EMR + RFA & sEMR were 3.5% (2%, 5%), 3% (2%, 4.5%) & 6%(4%, 10%), respectively. Detailed comparative analysis and secondary outcomes outlined in Tables 1 and 2. CONCLUSION: There was no difference in recurrence of neoplasia with any endoscopic modality. However, EMR + RFA had best safety profile as it was associated with lower risk of perforation as compared to ESD and lower risk of stricture formation and bleeding as compared to sEMR.Figure 1.: Forest plots for recurrence of neoplasia.Table 1.: Comparative analysis; Table 2. Secondary outcomes of interest

Efficacy and safety of endoscopic submucosal dissection versus endoscopic mucosal resection for superficial esophageal carcinoma: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) has been developed to overcome the limitations of endoscopic mucosal resection (EMR). Yet, the potential for EMR should not be ignored. This study aimed to compare the efficacy and safety of ESD and EMR in the treatment of superficial esophageal carcinoma (SEC). All relevant articles were retrieved from electronic databases. The primary outcomes included en bloc resection, curative resection, R0 resection, and local recurrence rates. Secondary outcomes included procedure time, rates of perforation, bleeding, and postoperative stricture. Subgroup analyses based on histologic types and lesion sizes were conducted. Twenty-two studies were enrolled. Overall results showed higher en bloc, curative, and R0 resection rate, and lower recurrence rate in ESD compared with EMR. ESD was significantly more time-consuming and induced more perforations than EMR procedure. In subgroup analyses of squamous cell carcinoma (SCC) and Barrett's esophagus (BE)-associated neoplasia and esophageal adenocarcinoma (EAC) subtypes, ESD also excelled in en bloc, curative, R0 resection and local recurrence rates. However, in subgroup analysis stratifying outcomes according to lesion sizes, the superior effect of ESD in en bloc resection, curative resection, and local recurrence rate only manifested when lesion size >20mm. Overall, ESD seemed to have superior efficacy and similar safety profiles compared to EMR in treating SCC, BE-associated neoplasia and EAC. Nevertheless, the selection of ESD or EMR should take lesion size into consideration. EMR is appropriate when lesion size ≤10mm, EMR and ESD are both applicable for lesion between 11 and 20mm, and ESD is preferable for lesions >20mm. More evidences are needed to confirm the current findings.

Carotid blowout—a rare but fatal complication of endoscopic submucosal dissection of superficial hypopharyngeal carcinoma after radiotherapy

Endoscopic submucosal dissection (ESD) has gained wide acceptance as a minimally invasive and curative surgery for superficial head and neck carcinoma. However, the safety of ESD for superficial pharyngeal carcinoma after radiotherapy has not been elucidated. Superficial hypopharyngeal carcinoma of the left pyriform sinus developed in a 76-year-old man who had undergone concurrent chemoradiotherapy for T2N2bM0 pyriform sinus carcinoma on the opposite side 12 months before. He underwent ESD without complications. Because tumor invasion into the muscular layer was a concern, the muscular layer was partially resected with the tumor. Twelve days after discharge, he presented with a sore throat and difficulty in swallowing. Endoscopy and computed tomography revealed necrosis due to wound infection with abscess formation around the left carotid artery. The common carotid artery subsequently ruptured. Although the surgical intervention was performed, he passed away 46 days after ESD due to carotid blowout. ESD is a minimally invasive treatment for superficial head and neck carcinoma, but carotid blowout can occur in cases after radiation. Prior radiotherapy and deeper dissection into the muscular layer may hamper wound epithelization, resulting in infection-induced necrosis and carotid blowout. Diligent monitoring of wound healing is essential in patients who have previously undergone irradiation.

An endoscopic treatment strategy for superficial tumors in patients with ulcerative colitis.

Endoscopic resection is feasible for superficial tumors in patients with ulcerative colitis; however, endoscopic resection options have not been evaluated comprehensively. We evaluated the efficacy and safety of endoscopic submucosal dissection and endoscopic mucosal resection, and decision making regarding endoscopic resection options for patients with ulcerative colitis. Endoscopically treated tumors from patients with ulcerative colitis were analyzed retrospectively. We evaluated en bloc and R0 resection, adverse events, local tumor recurrence, and metachronous lesion occurrence rates. We examined 102 tumors (mean size, 12mm; non-polypoid, 55 tumors) from 74 patients with ulcerative colitis, of whom, 39 and 63 underwent endoscopic submucosal dissection and endoscopic mucosal resection, respectively. The R0 resection rate was significantly higher for endoscopic submucosal dissection (97%) than for endoscopic mucosal resection (80%) (P=0.0015). For 11-20-mm tumors, the R0 resection rate was significantly higher for endoscopic submucosal dissection (94%) than for endoscopic mucosal resection (55%) (P=0.0027); the endoscopic submucosal dissection and endoscopic mucosal resection R0 rates did not differ for ≤10-mm tumors. The non-polypoid tumor R0 resection rates were significantly higher for endoscopic submucosal dissection (100%) than for endoscopic mucosal resection (65%) (P<0.001) and did not differ regarding the polypoid tumor R0 resection rates (75% vs 86%, P=0.49). Four patients experienced intraoperative perforation during endoscopic submucosal dissection. No local recurrences occurred. Metachronous high-grade dysplasia occurred in three patients during surveillance. In patients with ulcerative colitis, endoscopic submucosal dissection is suitable for ≥11-mm and non-polypoid tumors, whereas endoscopic mucosal resection is acceptable for ≤10-mm tumors.

Endoscopic submucosal dissection with an additional working channel (ESD+): a novel technique to improve procedure time and safety of ESD

Background and aimsA new external additional working channel (AWC) was recently introduced by which endoscopic submucosal dissection (ESD) can be converted to a technique termed “ESD+ ”. We aim to systematically evaluate this novel technique in flat gastric lesions and compare it to classical ESD.MethodsThe study was prospectively conducted in a pre-clinical ex vivo animal model (EASIE-R simulator) with porcine stomachs. Prior to intervention, we set standardized lesions measuring 3 cm or 4 cm in antegrade as well as in retrograde positions.ResultsOverall, 64 procedures were performed by an experienced endoscopist. Both techniques were reliable and showed en bloc resection rates of 100%. Overall, ESD+ reduced time of procedure compared to ESD (24.5 vs. 32.5 min, p = 0.025*). Particularly, ESD+ was significantly faster in retrograde lesions with a median of 22.5 vs. 34.0 min in 3 cm retrograde lesions (p = 0.002*) and 34.5 vs. 41.0 min (p = 0.011*) in 4 cm retrograde lesions. There were 0 perforations with both techniques. In ESD+ , 1 muscularis damage occurred (3.13%) compared to 6 muscularis damages with ESD (18.75%, p = 0.045*).ConclusionsBy its grasp-and-mobilize technique, ESD+ allows potentially faster and safer resections of flat gastric lesions compared to conventional ESD in an ex vivo porcine model. The potential advantages of ESD+ in terms of procedure time may be particularly relevant for difficult lesions in retrograde positions.

The impact of endoscopic submucosal dissection for gastric adenocarcinomas in the United States

Recent studies show promise for endoscopic submucosal dissection (ESD) in the United States, but do not identify the potential impact of ESD among newly diagnosed gastric cancers. We utilize the Veterans Health Administration to identify cancers suitable for ESD, to define the role of ESD in the United States. Retrospective cohort study using the Veterans Affairs Central Cancer Registry to identify patients with gastric cancer who underwent surgical resection from 1995 to 2018. TNM stage was used to categorize those who would meet absolute vs expanded indications for ESD. Primary outcome was lymph node status. Secondary analysis was performed with death as outcome. Of 12,584 primary gastric cancers, 4735 (37.6%) were nonmetastatic gastric adenocarcinomas. Median age at diagnosis was 70.3 years, 4676 (98.8%) male. Total 2306 (48.7%) underwent surgical resection, of which 636 (27.6%) were T1 lesions or cancer in situ. Of these, 44 (6.9%) met absolute indications for resection, 99 (15.6%) met established expanded criteria, and 98 (15.4%) may meet expanded criteria. Half of all tumors in each group were proximal in location. Rate of lymph node positivity was: 4.5%; 95% confidence interval [CI]: 0.5-15.5% in absolute group; 8.1%; 95% CI: 3.6-15.3% in expanded group; 13.3%; 95% CI: 7.3-21.6 in those potentially meeting expanded criteria. Lymph nodes positivity was associated with death (hazard ratio 1.49; 95% CI: 1.36-1.62, P < 0.001). Less than 10% of T1 or in situ cancers meet absolute criteria for ESD. Those that meet expanded criteria had higher risk for lymph node metastases, particularly proximal tumors. Future studies should evaluate the safety of ESD in proximal gastric tumors.

Mo1699 ADVANCED ENDOSCOPIC RESECTION TECHNIQUES FOR LOCAL RECURRENT COLORECTAL ADENOMAS: A SINGLE CENTER PROSPECTIVE STUDY

Local recurrence is a relatively frequent event after endoscopic mucosal resection (EMR), occurring in up to 20% of piecemeal resections. In these cases oncological radicality is mandatory to achieve, but endoscopic re-treatment can be technically challenging due to tissue scar. In this setting, advanced endoscopic resection techniques, such as endoscopic submucosal dissection (ESD) or endoscopic full thickness resection (FTR), could potentially allow en bloc large lesion removal for improved histopathological analysis and higher curative rates. However, to date few data are available on the use of these novel techniques for recurrent adenomas. Thus, the aim of our study was to access the efficacy and safety of ESD and FTR in the setting of post-polipectomy recurrence. We prospectively included all ESD and/or FTR performed for locally recurrent adenomas defined as lesions: 1) reappearing at the site that was previously treated endoscopically, 2) with convergent folds, and 3) with a polypectomy ulcer scar nearby. Data collection included lesions size, location and histology, endoscopic technique (ESD, FTR, hybrid-techniques), early (<48H)/ late complications, and recurrence at 3/6/12-month endoscopic follow-up. From April 2017 to January 2019 11 patients (M/F 5/6, median age 74yrs [IQR 69-80]) were included in the study. Recurrent adenomas had a median size of 17mm [IQR 10-24], being mostly located in the rectum (83%). In total 12 procedures were performed: n.5 ESD (two of which performed with hybrid ESD+EMR), n.6 FTR and hybrid ESD+FTR in one case. At histological examination eight lesions presented tubulovillous architecture, three of which with HGD; n.3 were tubular adenomas with LGD. Recurrence was not confirmed at pathology in one case, which was excluded for efficacy analysis (n.11). No major early/late complications were observed. Only one patient presented post-polypectomy syndrome resolved with medical therapy. 7/11 cases completed endoscopic assessment at 12 months with a median follow-up of 9.8 months [IQR 5-12]. Recurrence was observed in only one case three months after hybrid ESD+EMR; FTR re-treatment was performed with negative endoscopic follow-up at 3 months. In our experience advanced endoscopic techniques (ESD/FTR) performed alone or combined in one session or sequentially represent safe and effective treatment options for locally recurrent adenomas.

Tu1484 EFFICACY AND SAFETY OF ENDOSCOPIC SUBMUCOSAL DISSECTION OF EARLY GASTRIC NEOPLASIA IN THE WEST: RESULTS FROM FOUR TERTIARY REFERRAL EUROPEAN CENTRES

Endoscopic submucosal dissection (ESD) is a technique first developed in Japan to enable en-bloc endoscopic resection of early gastric neoplasia. The high prevalence of gastric neoplasia allowed for greater opportunity to train and refine the technique in the Far East. The same is not applicable to the West where the prevalence of gastric neoplasia is low. We aim to review the efficacy and safety of ESD for early gastric neoplasia from four large European referral centres. Data was prospectively collected on an electronic database. We analysed this database and patient’s electronic record. Parameters related to ESD outcome were collected. Data was analysed using SPSS software with logistic regression and multivariate analysis. A total of 264 gastric neoplasia lesions were resected between 2009 and 2019 (233 ESD, 31 hybrid ESD). Mean age was 72.0 years (range 38-91), and 150 patients were males (56.8%). 149 lesions (56.4%) were in proximal stomach. Mean size was 28.4mm (range 4-130mm). Mean duration of follow up is 8.2 months. Resection histology showed adenocarcinoma in 149 (56.7%) of cases, 21 (14.1%) of these were poorly differentiated. The overall en-bloc resection, R0, and recurrence rates were 93.5%, 83.3%, and 5.3%, respectively. Table (1) shows procedure-related complications, and table (2) summarizes predictors for R1 outcome. These included proximal location (OR 5.27, P=0.009), poor differentiation (OR 8.49, P=0.006), and LVI (OR 8.73, P= 0.007). There was no 30-day procedure related mortality. This is the largest western gastric ESD series, demonstrating the feasibility and safety of this technique in a European setting. Despite the relatively low R0 rate, our recurrence rate is low and comparable to Japanese data. Reasons behind good clinical outcome (low recurrence) despite average technical outcome (R0) remains uncertain.This raises a possibility that in the west, R-1 should not automatically be considered as an indication for surgery.Table (2)Multi-variate analysis showing predictors of outcomes (R1, recurrence) following gastric ESD in four European centres (N=264).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endoscopic Submucosal Dissection of Gastrointestinal Stromal Tumours: A Retrospective Cohort Study.

BackgroundGastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms. Endoscopic submucosal dissection (ESD) has been used to remove submucosal tumours for many years. However, whether ESD can be recommended for the treatment of GISTs is still controversial. Therefore, we evaluated the efficacy and safety of ESD for treating GISTs.Patients and MethodsWe retrospectively analysed 75 GIST patients who underwent ESD in our hospital from January 2016 to December 2018, and the demographic data, clinical presentation of tumours, operative parameters, postoperative complications and length of hospital stay were analysed.ResultsSeventy-five patients successfully underwent en bloc resection, and 74 (98.7%) patients underwent complete resection of the lesions, with an average tumour size of 1.7 cm (range 0.3–6.0 cm). The median operation time was 84.8 min (range 20–180 min). Forty-two (56.0%) patients underwent endoscopic purse-string suture with no conversions to an open operation. The median postoperative length of hospitalization was 6.6 days (range 3–14 days). Out of a total of 75 GIST patients, 48 (64.0%) were considered very low risk, 19 (25.3%) were low risk, 5 (6.7%) were mild risk, and 3 (4.0%) were high risk. The median follow-up was 24.0 months (range 6–45 months). During hospitalization and follow-up, no complications, recurrence or metastasis occurred.ConclusionBased on our study from a medical centre, ESD is a safe and effective method for treating GISTs. However, further studies are needed.

Endoscopic submucosal dissection (ESD) for Barrett's esophagus (BE)-related early neoplasia after standard endoscopic management is feasible and safe.

Background and study aims There is little data on the feasibility and safety of endoscopic submucosal dissection (ESD) as a salvage treatment for Barrett’s esophagus (BE)-related neoplasia after standard endoscopic treatments. Patients and methods A multicenter retrospective analysis on patients who underwent ESD for BE was performed. The primary endpoint was effectiveness of obtaining en-bloc resection in salvage as compared to non-salvage treatments. Results Median age was 71 (IQR 55 – 79) years. Twelve (37%) of 32 patients underwent salvage ESD. Median resection time was 100 (IQR 60 – 136) minutes. En-bloc resection was achieved in 31 patients (97 %). Complete R0 resection was obtained in 75 % in the salvage group and 80 % in the non-salvage group ( P = 1.00). In seven patients (22 %), the pre-ESD diagnosis was upgraded on post-ESD histopathology (1 low-grade dysplasia to high grade dysplasia [HGD], 4 HGD to early esophageal carcinoma (EAC), and 2 intramucosal EAC to invasive EAC). No perforations occurred in either group. Two late adverse events occurred, both in the salvage group ( P = 0.133). Delayed bleeding occurred in a patient who had just resumed warfarin and stricture occurred in a patient who had a circumferential resection requiring serial dilation and stent placement. Conclusions Our cohort study demonstrated that ESD as salvage therapy for BE related neoplasia is feasible and safe, achieving similar high rates of en-bloc resection and complete R0 resection as in treatment-naïve patients. Referral to an expert center performing ESD should be considered for patients with recurrence or progression following endoscopic mucosal resection or ablation therapy.

Outcomes of Endoscopic Submucosal Dissection for Subepithelial Lesions Localized Within the Submucosa, Including Neuroendocrine Tumors: A Multicenter Prospective Study.

Endoscopic submucosal dissection (ESD) seems to be a reasonable option for gastrointestinal subepithelial lesions (SELs) localized within the submucosa. Indications for ESD include small neuroendocrine tumors (NETs) and indeterminate SELs. However, the prospective data regarding ESD and surveillance remain unclear. This study was performed to prospectively investigate the outcomes of ESD, including organ-specific outcomes and the mid-term prognosis. This prospective multicenter study included 57 patients who underwent ESD for SELs localized within the submucosa [definite NETs (n = 42) and indeterminate SELs (n = 15)]. The efficacy and safety of ESD were evaluated in the whole cohort and in subgroups (NETs and indeterminate SELs). All patients were followed up. The rates of en bloc resection, curative resection, and complications were 98.2%, 66.7%, and 7.7% for the overall population (n=57); 100%, 61.9%, and 2.4% for NETs (n=42); and 93.3%, 80.0%, and 20.0% for indeterminate SELs (n=15), respectively. The rates of curative resection for NETs were poorer in the stomach (20%, n=5) and duodenum (33%, n=3) than in the rectum (71%, n=34). Including 11 of 16 patients with NETs who underwent a conservative approach resulting in non-curative resection, no patients developed tumor recurrence during the follow-up period (median, 24.5 months; range, 1-60 months). ESD followed by surveillance demonstrated acceptable mid-term outcomes for non-curative NETs. ESD can be an efficient therapy for SELs localized within the submucosa. However, gastric and duodenal ESD for NETs may be limited in terms of its curative and technical aspects. Clinicians should be aware of the potential complications of ESD for indeterminate SELs.

Endoscopic submucosal dissection for superficial esophageal neoplasms in elderly patients: A single-center, large-scale, retrospective study.

The number of elderly patients with superficial esophageal neoplasms has steadily increased, but few studies have focused on the clinical outcomes of esophageal endoscopic submucosal dissection in these patients. Therefore, the aim of our study was to investigate the feasibility and safety of endoscopic submucosal dissection among elderly patients with superficial esophageal neoplasms. Patients who underwent endoscopic submucosal dissection for superficial esophageal neoplasms between December 2005 and December 2017 were eligible. The patients were divided into two groups according to age: Not-old (<75 years, n = 369) and Old (≥75 years, n = 44). Clinical features and treatment outcomes were retrospectively investigated by reviewing medical records. In total, 413 patients with 459 lesions were enrolled in to this study. Comorbidities, except for a previous history of malignancy, were not significantly different between the two groups. Procedure-related characteristics and the rate of adverse events were similar in the two groups. During a median follow-up period of 33.4 months, the overall survival rate was lower in the Old group (P = 0.046), and the cumulative recurrence rate did not differ significantly between the two groups (P = 0.334). Based on these favorable outcomes, endoscopic submucosal dissection is as feasible and effective for the treatment of superficial esophageal neoplasms among elderly patients as it is among non-elderly patients. Geriatr Gerontol Int 2020; 20: 430-435.

Endoscopic submucosal dissection with double clip and rubber band traction for residual or locally recurrent colonic lesions after previous endoscopic mucosal resection.

Endoscopic submucosal dissection (ESD) of residual or locally recurrent (RLR) colonic lesions after previous endoscopic mucosal resection (EMR) is an attractive but challenging technique. The present study aimed to evaluate the effectiveness and safety of ESD with double clip and rubber band traction (DCT-ESD) of RLR colonic lesions. We retrospectively analyzed all consecutive DCT-ESD procedures for RLR colonic lesions (rectum excluded) performed in two French centers. The frequency of en bloc and R0 resections, procedure speed, additional surgery, and complications were evaluated. R0 resection was also used to investigate the learning curve. Among the 53 resections, 49 (92.5 %) were performed en bloc and 42 (79.2 %) achieved R0. The median procedure speed was 21 mm2/min. There were four (7.5 %) intraoperative perforations and one delayed bleeding; these were successfully treated endoscopically. There was no salvage surgery for complications. The R0 rate increased from 16/26 (61.5 %) for the first 26 procedures to 26/27 (96.3 %, P = 0.002) for the last 27 procedures. DCT-ESD appears to be a safe and effective treatment for RLR colonic lesions after EMR.

Efficacy and safety of endoscopic submucosal dissection using a scissors-type knife with prophylactic over-the-scope clip closure for superficial non-ampullary duodenal epithelial tumors.

This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors-type knife with prophylactic closure using over-the-scope clip (OTSC) for superficial non-ampullary duodenal epithelial tumors (SNADETs). Consecutive patients who underwent ESD for SNADETs >10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle-type knife (Flush Knife-ESD) or a scissors-type knife (Clutch Cutter-ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC. A total of 84 lesions were resected using the Flush Knife-ESD and the Clutch Cutter-ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter-ESD than that in the Flush Knife-ESD (97.9% vs 83.8%, respectively, P = 0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter-ESD than in the Flush Knife-ESD (0% vs 13.5%, respectively, P = 0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9%, 92.3%, and 98.2%, respectively (P = 0.021); and delayed perforation rates were 15.4%, 7.7%, and 1.8%, respectively (P = 0.092). Endoscopic submucosal dissection using a scissors-type knife with prophylactic OTSC closure is safe and feasible for the low-invasive treatment of SNADETs.

Feasibility and Safety of Endoscopic Submucosal Dissection for Recurrent Rectal Lesions that after Transanal Endoscopic Microsurgery: A Case Series

Objectives: Recently, several studies have demonstrated the usefulness of endoscopic submucosal dissection (ESD) for residual or locally recurrent colorectal lesions after endoscopic treatment. However, the feasibility of ESD for recurrent rectal lesions after transanal endoscopic microsurgery (TEM) has not been fully investigated. In this study, we evaluated the feasibility and safety of ESD for recurrent rectal lesions after TEM. Methods: The treatment outcomes of 10 lesions in 9 patients, who underwent ESD between January 2006 and March 2018 for recurrent rectal lesions after transanal endoscopic microsurgery, were evaluated. Results: All lesions were successfully resected en bloc, and the R0 resection rate was 90%. The median size of the resected specimens and lesions (range) was 44 mm (21–70) and 27.5 mm (5–60), respectively. The pathological diagnoses included 4 adenomas and 6 cancerous lesions. The cancerous lesions included 5 cases of mucosal cancer and 1 case of superficial submucosal invasive cancer (depth of submucosal invasion <1,000 μm from the muscularis mucosae). No adverse events occurred. There was no recurrence during the follow-up period. Conclusions: ESD for recurrent rectal lesions after TEM by expert’s hands appears to be safe and feasible.

A Single-Center Early Experience of Endoscopic Submucosal Dissection for Gastric Lesions in Thailand.

Endoscopic submucosal dissection (ESD) was also considered a “high risk” at the starting point with skillful endoscopic techniques and terrible complications. Still, it remains challenging yet has become widespread among institutes in many parts of the world. This study is aimed at further investigating the feasibility, efficacy, and safety of ESD of gastric lesions and at evaluating clinical outcomes in early experience. The patient characteristics, postoperative outcomes, and results of histopathological examinations were reviewed retrospectively between January 2017 and May 2019. Thirteen patients' gastric ESD were included with all of en bloc resections without recurrence. The long duration was related to the large lesion, the upper part of the stomach, and previous treatment. In this study, the ESD procedure of the stomach is a feasible and safe minimally invasive treatment option with organ preservation. It requires training and experience with a learning approach where skill may be improved to prevent unwanted complications.

Short- and long-term outcomes of endoscopic submucosal dissection for non-ampullary duodenal neuroendocrine tumors.

BackgroundEndoscopic resection is recommended for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤10 mm in diameter and confined to the submucosal layer, without lymph node or distant metastasis. However, the efficacy and safety of endoscopic submucosal dissection (ESD) for NAD-NET remains unclear. The aim of this study was to assess the short-term efficacy and safety and the long-term outcomes of ESD for NAD-NET.MethodsEight patients with 8 NAD-NETs who underwent ESD between 2015 and 2018 were included. The indications for ESD were: i) tumor ≤10 mm in diameter; ii) NET G1; iii) confined to the submucosal layer; and iv) without lymph node or distant metastasis. We retrospectively assessed the short- and long-term outcomes and safety.ResultsThe median patient age was 69 (48-76) years. All tumors were located in the duodenal bulb and showed 0-Is morphology. The median size was 6.4 (3-9.3) mm. The rates of en bloc resection, histologically free horizontal and vertical margins, and curative resection were 100%, 88%, and 88%, respectively. Intraoperative and postoperative perforation each occurred in 13% of patients, all of whom were treated conservatively and avoided emergent surgery. Delayed bleeding was not observed. No local, lymph node or distant recurrence was observed during a median follow-up period of 34 (18.5-62.5) months.ConclusionsThe rates of en bloc and curative resection, and histologically free margins were sufficiently high. Although intraoperative and postoperative perforations occurred, emergency surgery was not needed. The results show that ESD is an efficacious and safe treatment for NAD-NET.