Standard Endoscopic Submucosal Dissection Research Articles

Endoscopic Submucosal Dissection of Superficial Colorectal Neoplasms at "Challenging Sites" Using a Double-Balloon Endoluminal Interventional Platform: A Single-Center Study.

Colonic endoscopic submucosal dissection (ESD) at "challenging sites" such as the cecum, ascending colon, and colonic flexures could be difficult even for expert endoscopists due to poor endoscope stability/maneuverability, steep angles, and thinner wall thickness. A double-balloon endoluminal intervention platform (EIP) has been introduced in the market to fasten and facilitate ESD, particularly when located at difficult sites. Here, we report our initial experience with an EIP comparing the outcomes of an EIP versus standard ESD (S-ESD) at "challenging sites". We retrospectively collected data on consecutive patients with colonic lesions located in the right colon and at flexures who underwent ESD in our tertiary referral center between March 2019 and May 2023. Endoscopic and clinical outcomes (technical success, en bloc resection rate, R0 resection rate, procedure time, time to reach the lesion, and adverse events) and 6-month follow-up outcomes were analyzed. Overall, 139 consecutive patients with lesions located at these challenging sites were enrolled (EIP: 31 and S-ESD: 108). Demographic characteristics did not differ between groups. En bloc resection was achieved in 92.3% and 93.5% of patients, respectively, in the EIP and S-ESD groups. Both groups showed a comparable R0 resection rate (EIP vs. S-ESD: 92.3% vs. 97.2%). In patients undergoing EIP-assisted ESD, the total procedure time was shorter (96.1 [30.6] vs. 113.6 [42.3] minutes, p = 0.01), and the mean size of the resected lesions was smaller (46.2 ± 12.7 vs. 55.7 ± 17.6 mm, p = 0.003). The time to reach the lesion was significantly shorter in the EIP group (1.9 ± 0.3 vs. 8.2 ± 2.7 min, p ≤ 0.01). Procedure speed was comparable between groups (14.9 vs. 16.6 mm2/min, p = 0.29). Lower adverse events were observed in the EIP patients (3.8 vs. 10.2%, p = 0.31). EIP allows results that do not differ from S-ESD in the resection of colorectal superficial neoplasms localized in "challenging sites" in terms of efficacy and safety. EIP reduces the time to reach the lesions and may more safely facilitate endoscopic resection.

Magnetic ring-assisted endoscopic submucosal dissection for gastric lesions with submucosal fibrosis: A preliminary study in beagle model.

During endoscopic submucosal dissection (ESD) for gastric lesions with fibrosis, appropriate traction could provide clear submucosal dissection visualization to improve safety and efficiency of procedures. Therefore, the aim of this study was to evaluate the feasibility of magnetic ring-assisted ESD (MRA-ESD) for gastric fibrotic lesions. In the eight healthy beagles, 2-3mL of 50% glucose solution was injected into submucosal layer of the stomach to induce gastric fibrotic lesions. A week after submucosal injection, two endoscopists at different levels performed MRA-ESD or standard ESD (S-ESD) for gastric simulated lesions, respectively. The magnetic traction system consisted of external handheld magnet and internal magnetic ring. The feasibility and procedure outcomes of the magnetic traction system were mainly evaluated. Forty-eight gastric simulated lesions with ulceration were confirmed to have submucosal fibrosis formation by preoperative endoscopic ultrasonography. The magnetic traction system could be easily established, only took 1.57min, and allowed excellent submucosal visualization. The total procedure time was significantly shorter in the MRA-ESD group than in the S-ESD group for both endoscopists (mean: 46.83 vs. 25.09min, p<0.001), and this difference was accentuated in non-skilled endoscopist. There was significant difference between two groups in bleeding and perforation rates. Histological analysis showed the depth of resected specimens was a little deeper around the fibrotic portion in the S-ESD group (p<0.001). The magnetic ring-assisted ESD technique may be an effective and safe treatment for gastric fibrotic lesions and may shorten the endoscopic learning curve for non-skilled endoscopists.

Pilot study on a new endoscopic platform for colorectal endoscopic submucosal dissection.

The endoscopic submucosal dissection (ESD) is a technically demanding and time-consuming procedure, with an increased risk of adverse events compared to standard endoscopic resection techniques. The main difficulties are related to the instability of the operating field and to the loss of traction. We aimed to evaluate in a pilot trial a new endoscopic platform [tissue retractor system (TRS); ORISE, Boston scientific Co., Marlborough, MA, USA], designed to stabilize the intraluminal space, and to provide tissue retraction and counter traction. We prospectively enrolled all consecutive patients who underwent an ESD for sigmoid/rectal lesions. The primary outcome was the rate of technical feasibility. Further technical aspects such as en-bloc and R0 resection rate, number of graspers used, circumferential incision time, TRS assemblage time, submucosal dissection time, and submucosal dissection speed were provided. Clinical outcomes (recurrence rate and adverse events) were recorded as well. In all, 10 patients (M/F 4/6, age: 70.4 ± 11.0 years old) were enrolled. Eight out of 10 lesions were located in the rectum. Average lesion size was 31.2 ± 2.7 mm, and mean lesion area was 1628.88 ± 205.3 mm2. The two sigmoid lesions were removed through standard ESD, because the platform assemblage failed after several attempts. All rectal lesions were removed in an en-bloc fashion. R0 resection was achieved in 7/8 (87.5%) patients in an average procedure time of 60.5 ± 23.3 min. None of the patients developed neither intraprocedural nor postprocedural adverse events. TRS-assisted ESD is a feasible option when used in the rectum, with promising result in terms of efficacy and safety outcomes. Nevertheless, our pilot study underlines few technical limitations of the present platform that need to be overcome before the system could be widely and routinely used.

Use of a novel endoscopic overtube with bilateral tool channels for endoscopic resection of experimental lesions and repair of intestinal defects in the right colon: preclinical trial.

Endoscopic tumor resection and intestinal defect repair are technically challenging leading to invasive surgery and colectomy performed for resection of benign polyps. In this study, we evaluated the use of an endoscopic overtube with bilateral tool channels for these procedures. Using a fresh porcine colorectum in a 3D ex vivo model, 3cm lesions at the posterior wall of the transverse colon were removed by two different techniques: standard endoscopic submucosal dissection (ESD) technique (STD, n = 12) and ESD using the overtube with an endoscopic snare and grasper through the bilateral channels (OT, n = 12). Procedure times and the number of muscular injuries were evaluated. Using the same model, 5-10mm full-thickness perforations within a 3cm mucosal defect at the posterior wall of the transverse colon were closed by two different techniques: standard endoscopic closure technique (STD, n = 12) and endoscopic closure using the overtube with two graspers (OT, n = 12). The outcomes measured included bursting pressure and the number of endoscopic clips used for closure. Endoscopic resection of lesions was performed by the OT group in a significantly shorter total procedure time (STD vs. OT = median 38.9min vs. 17.3, p < 0.001) and with fewer muscular injuries (median 0 vs. 2, p = 0.002), compared with the STD group. After repair of intestinal defects, the OT group showed higher median bursting pressures (STD vs. OT = 11.2mmHg vs. 57.1, p = 0.008) despite using fewer clips (median 13 vs. 10, p < 0.001). This study demonstrates a novel traction technique with an endoscopic overtube using multiple instruments to remove lesions and repair intestinal defects in the colon more effectively. This endoscopic platform could provide a safe alternative to invasive surgical treatment.

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

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

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.

EMR and ESD: Indications, techniques and results

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are two well-known endoscopic resection procedures used for advance gastrointestinal lesions. As compared to standard polypectomy techniques, EMR and ESD provide wider and deeper resection margins and allow en bloc removal of lesions for more detailed pathology with curative intent for early neoplastic gastrointestinal lesions. Both procedures have their advantages and disadvantages which will be discussed in detail in this review article. Recently there have been advancements in the techniques of EMR and ESD with addition in new equipment. We will also discuss current guidelines recommending use of EMR and/or ESD in various clinical scenarios.

Technical feasibility of salvage endoscopic submucosal dissection after chemoradiation for locally advanced rectal adenocarcinoma

The standard treatment of locally advanced rectal cancer is chemoradiation (CRT) followed by proctectomy and adjuvant chemotherapy. However, there is an emerging role for nonsurgical management after CRT or total neoadjuvant therapy (TNT) consisting of CRT and neoadjuvant chemotherapy. Endoscopic submucosal dissection (ESD) after CRT or TNT for rectal cancer, termed "salvage ESD," may be a viable nonsurgical option for carefully selected patients. We aimed to evaluate the feasibility and safety of salvage ESD. A retrospective chart review of cases of salvage ESD for locally advanced rectal cancer and standard ESD for rectal tumors without prior CRT from July 2018 to August 2020 at our institution was performed. Clinical factors and imaging, procedural, and pathology results were collected and compared. Twelve salvage ESD cases were compared with 27 standard ESD cases. Before CRT, 83.3% of lesions in the salvage ESD group were initially clinically staged as T3. The en-bloc resection rates were 92.7% and 91.7% (P= 1.00) and R0 resection rates 66.7% and 75.0% (P= .55) for the standard and salvage groups, respectively. In the salvage ESD group, no adverse events were observed, and 75.0% of the adenocarcinomas in the salvage ESD group had morphologically changed to hyperplasia or adenoma after CRT, with no identifiable lesions greater than T1 tumor depth. Salvage ESD for locally advanced rectal cancer is technically feasible with low adverse event rates. There may be a diagnostic role in salvage ESD in assessing pathologic response to CRT and a possible therapeutic role in resection of residual lesions with the potential to avoid surgery.

Evaluating the technical feasibility of novel salvage endoscopic submucosal dissection after chemoradiotherapy for locally advanced rectal adenocarcinoma.

103 Background: According to the National Comprehensive Cancer Network guideline, locally advanced rectal cancer is treated with chemotherapy with or without radiation, followed by transabdominal resection. However, there has been an emerging role for nonoperative management after chemoradiotherapy, and there is significant morbidity and risks associated with surgical resection. Endoscopic submucosal dissection (ESD) after chemoradiotherapy (CRT) for rectal cancer, which is termed “salvage ESD,” may be a viable option for patients, in terms of evaluating pathological response and providing potential curative resection. We aim to evaluate the feasibility and safety of salvage ESD. Methods: Retrospective chart review of cases of salvage ESD after CRT for locally advanced rectal cancer (salvage group) and standard ESD cases for rectal tumors without prior CRT (standard group) from July 2018 to August 2020 at our institution was performed. Clinical factors, imaging, procedural, and pathology results were collected and compared between the two groups. Results: 12 salvage ESD cases were compared to 27 standard ESD cases. 83.3% of the lesions in the salvage ESD group were initially staged as T3 prior to CRT. 100% of the lesions in the salvage ESD group were scarred down, compared to 33.3% in the standard ESD group (p &lt;0.01). Technical outcomes are shown in the table. The en bloc resection rates were 92.7% and 91.7% (p=1.00) and R0 resection rates were 66.7% and 75.0% (p=0.55) for the standard and salvage groups, respectively. In the salvage ESD group, no adverse events were observed. 66.7% of the adenocarcinomas in the salvage ESD group had morphologically changed to hyperplasia or adenoma after CRT and there were no identifiable lesions greater than T1 staging. Conclusions: Salvage ESD after CRT for locally advanced rectal cancer is technically feasible and with comparable low complication rates. There may be a diagnostic role in salvage ESD in assessing pathological response to CRT, as well as a possibly therapeutic role in resection of residual lesions with the potential to avoid surgery. Further studies are underway comparing the clinical outcomes of salvage ESD with standard surgical resection after CRT for locally advanced rectal cancer.[Table: see text]

Endoscopic submucosal dissection for colorectal neoplasia: outcomes and predictors of recurrence

Background and study aims The role of endoscopic submucosal dissection (ESD) for colorectal lesions in Western communities is unclear and its adoption is still limited. The aim of this study is to assess the long-term outcomes of a large cohort of patients treated with colorectal ESD in a tertiary Western center. Patients and methods A retrospective analysis was conducted on patients treated by ESD for superficial colorectal lesions between February 2011 and November 2019. The primary outcome was the recurrence rate. Secondary outcomes were en-bloc and R0 resection rates, procedural time, adverse events (AEs), and need for surgery. The curative resection rate was assessed for submucosal invasive lesions. Results A total of 327 consecutive patients, median age 69 years (IQR 60–76); 201 men (61.5 %) were included in the analysis. Of the lesions, 90.8 % were resected in an en-bloc fashion. The rate of R0 resection was 83.1 % (217/261) and 44.0 % (29/66) for standard and hybrid ESD techniques, respectively. Submucosal invasion and piecemeal resection independently predicted R1 resections. A total of 18(5.5 %) intra-procedural AEs (perforation:11, bleeding:7) and 12(3.7 %) post-procedural AEs occurred (perforation:2, bleeding: 10). Eighteen adenoma recurrences per 1,000 person-years (15cases, 5.6 %) were detected after a median follow-up time of 36 months. All recurrences were detected within 12 months. No carcinoma recurrences were observed. R1 resection status and intra-procedural AEs independently predicted recurrences with seven vs 150 recurrences per 1,000 person-years in the R0 vs R1 group, respectively. Conclusions Colorectal ESD is a safe and effective option for managing superficial colorectal neoplasia in a Western setting, with short and long-terms outcomes comparable to Eastern studies. En-bloc R0 resection and absence of intra-procedural AEs are associated with reduced risk of recurrence.

Use of an endoscopic flexible grasper as a traction tool for excision of polyps: preclinical trial

Endoscopic submucosal dissection (ESD) is challenging in the right colon. Traction devices can make it technically easier. In this study, we evaluated a flexible grasper with articulating tip and elbow-like bending (IgE) through a double-balloon surgical platform (DESP), compared with an earlier generation grasper without elbow-like bending (Ig). The reach of Ig/IgE was investigated at eight locations using a synthetic colon within a 3D model. Using a fresh porcine colorectum, 4 cm pseudo-polyps were created at the posterior wall of the ascending colon. Fifty-four ESD procedures were performed using three techniques: standard ESD (STD), ESD using Ig (DESP + Ig), and ESD using IgE (DESP + IgE). IgE was able to reach the full circumference at all the locations, whereas the medial walls proximal to the descending colon were out of Ig’s reach. Compared with the STD, both DESP + Ig and DESP + IgE showed significantly shorter procedure time (STD vs. DESP + Ig vs. DESP + IgE = median 48.9 min vs. 38.6 vs. 29.9) and fewer injuries (1.5 vs. 0 vs. 0). Moreover, the DESP + IgE had a shorter procedure time than the DESP + Ig (p = 0.0025). The IgE with DESP increased instrument reach compared to Ig, and likely represented a traction tool for excision of large pseudo-polyps in the right colon.

Quantifying early gastric cancer in Australia: What is the opportunity for gastric endoscopic submucosal dissection?

Endoscopic submucosal dissection (ESD) is the recommended treatment for early gastric cancer (EGC). However, there are challenges in attaining expertise in ESD in countries where the incidence of gastric cancer and proportion diagnosed at an early stage of disease are relatively low. This study aims to establish the proportion of gastric cancer meeting histological criteria for EGC, which may be suitable for ESD, in a Western population. Gastric cancers reported to the Victorian Cancer Registry between January 2011 and December 2016 were analyzed. EGC was defined as tumor confined to mucosa (T1a) or submucosa (T1b). Histology reports were analyzed using Japanese and European guidelines to identify potential ESD candidates. Criteria for extended ESD were based on grade of differentiation, tumor depth, lymphovascular and perineural invasion, and ulceration. Twenty percent of 1217 gastric cancers was EGC (237 cases), with detailed histopathology reports suitable for evaluating ESD criteria recorded in 182 cases. Standard and extended ESD criteria were met in 46% (84/182) and 75% (132/182), respectively. Actual treatment of the 237 EGC was endoscopic in 14% (n=33) and surgery in 86% (n=204). Endoscopically treated EGCs were more likely to be stage T1a and located in the proximal stomach. EGCs represented 20% of reported gastric adenocarcinomas with the majority fulfilling criteria for ESD. ESD should be considered in the management algorithm and discussed at tumor board meetings involving interventional endoscopists. To increase utilization of ESD, systems need to be implemented to improve training, accreditation, and access to ESD.

Simplified magnetic anchor-guided endoscopic submucosal dissection: an ex vivo porcine model.

Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. A total of 15 en bloc ESDs (five with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90 min. Lesion size ranged from 15 to 50 mm (mean 30 mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.

The learning experience for endoscopic submucosal dissection in a non-academic western hospital: a single operator's untutored, prevalence-based approach.

BackgroundStudies of learning experience in endoscopic submucosal dissection (ESD) commonly originate from the East. Little is known about the performance of ESD in low-volume western centers. Furthermore, it is unclear whether ESD can be self-taught without a tutored approach.MethodsWe performed a retrospective analysis of consecutive ESDs, performed in an untutored prevalence-based fashion by a single operator at a private Greek hospital from 2016-2020. Out of 60 lesions, standard ESD was applied for 54 and enucleation for 6; 41 were mucosal and 19 submucosal; 3 esophageal, 24 gastric, one duodenal, 12 colonic, and 20 rectal.ResultsPathology revealed carcinoma (n=14), neuroendocrine tumor (n=7), precancerous lesion (n=27), or other submucosal tumors (n=12). The rates of en bloc and R0 resection were 98% and 91%, respectively. The median resection speed was <3 cm2/h for the first 20 cases, but improved progressively to ≥9 cm2/h after 40 cases. Two patients underwent laparoscopic surgery for colonic perforation, and one received a blood transfusion because of delayed bleeding (serious adverse event rate: 5%). No deaths occurred. The median hospital stay was 1.3 days. Variables associated with improvement in ESD speed during the second period of the study were the application of countertraction and the experience acquired through other endosurgical techniques.ConclusionsESD was safe and effective in a low-volume center, with an acceptable adverse events rate. At least 40 mixed cases were needed to achieve a high resection speed. Additive experience gained through other endosurgical procedures probably contributed to the improvement in performance.

Endoscopic submucosal dissection of large polyps in the right colon using an endoscopic snare with a double-balloon endolumenal interventional platform: an ex vivo study in a porcine colorectal model.

Endoscopic submucosal dissection (ESD) is a challenging procedure for the removal of colorectal tumors, especially tumors located in the right colon. The use of traction could make this procedure technically easier and reduce procedure times and complication rates. In this study, we demonstrated the feasibility and utility of a traction technique utilizing an endoscopic snare through an overtube, a double-balloon endolumenal interventional platform (DEIP) in a porcine colorectal model. A total of 120 procedures were performed using three different techniques: standard ESD technique (STD), ESD with DEIP (DEIP alone), and ESD with DEIP and a snare (DEIP + Snare). The snare was passed inside the overtube and used as a grasper on the tissue to provide traction. Lesions 3 or 4cm in diameter were removed with a 5mm margin from the anterior and posterior walls of the proximal Transverse Colon, the Hepatic Flexure, and the posterior wall of the Cecum. The outcomes measured included procedure times and the number of muscularis propria injuries. The DEIP + Snare group showed significantly shorter total procedure and submucosal dissection times for lesions in all locations (median 28.1min (DEIP + Snare, n = 32) vs 39.8 (STD, n = 32) vs 39.7 (DEIP alone, n = 32); 7.5min vs 25.3 vs 25.1) and had fewer muscularis propria injuries (median 0 [range 0-2] vs 2 [0-7] vs 1 [0-6]) than the two other groups. Larger lesions (4cm) were successfully removed by regrasping the tissue in DEIP + Snare group, which showed significantly shorter total procedure time [31.4min (DEIP + Snare, n = 8) vs 40.1 (STD, n = 8) vs 45.6 (DEIP alone, n = 8)] and submucosal dissection time (12.3min vs 27.6 vs 29.1) than the two other groups. ESD traction technique with an endolumenal platform and snare enables faster removal of large polyps in the right colon with fewer injuries than standard methods of ESD.

ESD with double-balloon endoluminal intervention platform versus standard ESD for management of colon polyps.

Background and study aims Endoscopic submucosal dissection (ESD) with the double-balloon endoluminal intervention platform (DEIP) is a novel technique for removal of complex colon polyps (> 2 cm) or those located in anatomically difficult positions. DEIP helps create a therapeutic zone with improved visualization and stability, facilitating polyp removal. We aimed to compare the outcomes of DEIP with the conventional cap-assisted ESD (standard ESD) technique for colon polyp resection, in particular, the ability to complete the ESD procedure without resorting to hybrid ESD or piecemeal resection. Patients and methods This was a retrospective cohort of all patients who underwent colon ESD in a single large tertiary referral center between September 2016 and October 2019. Information was collected on patient demographics and study outcomes including procedure time, rates of en bloc and curative resection, operative and postoperative complications. All patients were followed up for 1 month after the procedure. Results 111 patients were included in the study (DEIP 60, standard ESD 51). There was no statistically significant difference between mean procedures time (± SD) in the two groups, mean (81.9 ± 35.4 min standard vs. 96.4 ± 42.2 min in DEIP). Mean polyp size (± SD) was similar between the two groups (7.6 ± 6.0 cm 2 vs. 6.2 ± 5.5 cm 2 , P = .2). There were no significant differences in en bloc and curative resection rates or operative and postoperative complications between the two techniques. Conclusion Procedure time was similar using both techniques. However, DEIP enabled the entire procedure to be performed using the ESD technique without resorting to snare resection, which may affect the en bloc and curative resection rate. There were no significant differences in en bloc and curative resection rates between the two groups, probably due to the small sample size.

Effectiveness and safety of underwater techniques in gastrointestinal endoscopy: a comprehensive review of the literature

Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), represent the standard of care for treatment of superficial gastrointestinal lesions. In 2012 a novel technique called underwater endoscopic mucosal resection (U-EMR) was described by Binmoeller and colleagues. This substantial variation from the standard procedure was afterwards applied at endoscopic submucosal dissection (U-ESD) and recently proposed also for peroral endoscopic myotomy (U-POEM) and endoscopic full-thickness resection (U-EFTR). This paper aims to perform a comprehensive review ofthe current literature related to supporting the underwater resection techniques with the aimto evaluate their safety and efficacy. Based on the current literature U-EMR appears to be feasible and safe. Comparison studies showed that U-EMR is associatedwithhigher "en-bloc" and R0 resection rates for colonic lesions, but lower "en-bloc" and R0 resection rates forduodenal non-ampullary lesions, compared to standard EMR. In contrast to U-EMR, little evidence supporting U-ESD are currently available. A single comparison study on gastric lesions showed that U-ESD had shorter procedural times and allowed a similar "en-bloc" resection rates compared to standard ESD. No comparison studies between U-ESD and ESD are available for colonic lesions. Finally, only some anecdotal experiences have been reported for U-POEM or U-EFTR, and the feasibility and effectiveness of these techniques need to be further investigated. Further prospective studies are necessary to better explore the advantages of underwater techniques compared to the respective standards of care, especially in the setting of U-ESD where consistent data are lacking and where standardization of the technique is needed.

Endoscopic submucosal dissection with a novel high viscosity injection solution (LiftUp) in an ex vivo model: a prospective randomized study.

Introduction Endoscopic submucosal dissection (ESD) is increasingly being used in the western world. Submucosal injectates are an essential tool for the ESD procedure. In this study, we evaluated a novel copolymer injectate (LiftUp, Ovesco, Tübingen Germany) in an established ESD model (EASIE-R) in comparison to existing submucosal injectables. Materials and methods We conducted a prospective, randomized ex vivo study performing ESD with three injectates: LiftUp, hydroxyethyl starch (HAES 6 %) and normal saline solution (NaCl 0.9 %). A total of 60 artificial lesions, each 3 × 3 cm in size, were resected in an ex vivo porcine model, utilizing one of the three studied injectates (n = 20 ESDs per injectate). Study parameters were: en bloc resection rate, perforation rate, lifting property, time of injection, injectate volume, general ESD procedure time, and overall procedure time. Results All 60 lesions were successfully resected using the standard ESD technique. LiftUp had no procedure related perforations, one perforation occurred in the HAES group, and two perforations in the NaCl group ( P > 0.05). Furthermore, adequate lifting was achieved in 16/20 (80 %) using LiftUp, 6/20 (30 %) in the HAES group and 6/20 (30 %) in the NaCl group ( P < 0.0002). En bloc resection was achieved in 19 (95 %) with LiftUp, in 20 (100 %) with HAES, and in 16 (80 %) with NaCl. General ESD procedure time and overall procedure time were not different among the three groups. Conclusion LiftUp appears to be a safe alternative to established fluids for ESD. It had a significantly improved lifting effect and required significantly less injected volume compared to well-established lifting solutions.

Saline-pocket endoscopic submucosal dissection for superficial colorectal neoplasms: a randomized controlled trial (with video)

Colorectal endoscopic submucosal dissection (ESD) is a time-consuming procedure because of the technical difficulty. The newly developed saline-pocket ESD (SP-ESD) provides a clearer view and better traction of the submucosal layer compared with the standard ESD with gas insufflation (S-ESD). This study aimed to prospectively compare the efficacy and safety between S-ESD and SP-ESD in patients with superficial colorectal neoplasms (SCNs). From April 2017 to November 2018, 95 patients with SCNs≥20mm in diameter were prospectively and randomly enrolled. Four patients were excluded because of an incomplete ESD procedure. Patients were finally allocated to 2 groups, S-ESD with 45 patients and SP-ESD with 46 patients. The primary outcome was dissection speed. Secondary outcomes were ESD procedure time, en bloc and complete resection rates, perforation rate, and adverse effects. Median dissection speed was significantly faster in the SP-ESD than the S-ESD group (20.1mm2/min [range, 17.3-28.1] vs 16.3mm2/min [range, 11.4-19.8]; P< .001). Median procedure time was significantly shorter in the SP-ESD than the S-ESD group (29.5 minutes [range, 22.3-44] vs 41 minutes [range, 31-55]; P< .001). The en bloc and complete resection rates were 100% in both groups. No perforations occurred among patients. The volume of saline solution used in the SP-ESD group was significantly greater than that in the S-ESD group (200 mL [range, 120-250] vs 150 mL [range, 100-200]; P= .016). SP-ESD improved dissection speed and procedure time compared with S-ESD. SP-ESD may be analternative method for resection of SCNs. (Clinical trial registration number: UMIN 000026317.).

Current Status of Endoscopic Resection of Gastric Subepithelial Tumors.

Most gastrointestinal (GI) subepithelial tumors (SETs) are identified incidentally during endoscopic examination and are located in the stomach. Some SETs are malignant or have the potential to become malignant. Tumors originating from deeper layers, such as the muscularis propria or serosa, are not easy to diagnose and resect. Current guidelines recommend yearly endoscopic surveillance of SETs smaller than 2 cm. This recommendation may not be cost-effective in managing GI SETs. Endoscopic resection results not only in obtaining sufficient tissue for pathological diagnosis but also in resection and curing the tumor. Many different endoscopic methods for resection of GI SETs have been published in the literature. To avoid confusion, we have divided these methods into standard endoscopic submucosal dissection, modified endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and nonexposed and exposed endoscopic full-thickness resection. These procedures offer less invasive approaches than surgery for resection of GI SETs and may be the most cost-effective in taking care of patients with GI SETs.