Endoscopic resection using an over-the-scope clip for duodenal neuroendocrine tumors

Abstract Background and study aims Endoscopic resection of duodenal neuroendocrine tumors (DNETs) remains controversial, and its indications are still unclear. This study aimed to evaluate short-term outcomes of a newly developed endoscopic muscularis resection (EMR) method that utilizes an over-the-scope clip (OTSC), termed EMRO, for treating DNETs. Patients and methods In total, 13 consecutive patients with 14 small (≤ 10 mm) DNETs who underwent EMRO from September 2017 to March 2020 were retrospectively enrolled. EMRO was performed by a single experienced endoscopist. Patients’ characteristics and treatment outcomes were assessed. Results The En bloc and R0 resection rates were 100 % (14/14) and 92.9 % (13/14), respectively. The median pathological resected specimen size was 10 mm, with a median pathological resected tumor size of 6 mm. During the EMRO procedure, there was no occurrence of misplacement of the OTSC to the target lesion. With respect to the pathological resection depth, nine cases (64.3 %) and five cases (35.7 %) were categorized as deep submucosal resection and muscularis resection, respectively, whereas no case was categorized as full-thickness resection. There were no intraoperative or delayed perforations. However, delayed bleeding occurred in two cases. At a median follow-up of 12 months (range 7–36) after EMRO, there was no incidence of local recurrence. At the first follow-up endoscopy performed at 6 months after EMRO, the OTSC was retained in place in two of 14 DNETs (14.3 %). Conclusions EMRO can be performed safely, by an experienced endoscopist, for small (≤ 10 mm) DNETs.

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Endoscopic Resection of Esophageal Granular Cell Tumors: A Single Center Experience

10.21203/rs.3.rs-729078/v1 ◽

2021 ◽

Author(s):

Kaipeng Liu ◽

Yangyang Zhou ◽

Qingfen Zheng ◽

Dan Liu ◽

Huiyu Yang ◽

...

Keyword(s):

Endoscopic Resection ◽

Muscularis Propria ◽

Granular Cell ◽

En Bloc Resection ◽

Clinicopathological Characteristics ◽

Maximum Diameter ◽

R0 Resection ◽

En Bloc ◽

Delayed Bleeding ◽

The Mean

Abstract Background: Granular cell tumors (GCTs) are rare tumors probably originating from neurogenic Schwann cells. The aim was to evaluate the safety and feasibility of endoscopic resection for esophageal GCTs. Methods: The study retrospectively analyzed patients with pathologically diagnosed esophageal GCTs in our center from February 2012 to December 2020. Clinicopathological characteristics, endoscopic features and clinical outcomes were collected and analyzed. Results: 12 males and 10 females were identified. Lesions were located in the upper, middle and lower esophagus in three, six and thirteen cases respectively. 14 lesions (63.6%) exhibited white-to-yellow discoloration. The mean maximum diameter of these lesions was 5.7±2.2 mm (range 2-11.6 mm). The most lesions (91%) were located in the mucosa or submucosa layer, and 2 lesions (9.0%) were in the muscularis propria layer. Endoscopic mucosal resection (n=17), endoscopic submucosal dissection (n=4) and endoscopic submucosal excavation (n=1) were performed. En bloc resection was achieved in 20 lesions (90.9%). The R0 resection was achieved in 20 lesions (90.9%). No patients experienced intraoperative perforation or delayed bleeding in the mean length of postoperative hospital stay of 4.2±2.1 days (range 1-9 days). All patients had no recurrence or metastasis during the mean follow-up period of 48.1±27.2 months (range 2-102 months). Conclusion: Endoscopic resection is safe and effective for management of esophageal GCTs. Clinically, the appropriate approach of endoscopic resection should be selected according to the origin and size of the lesion.

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The band and slough technique is effective for management of diminutive type 1 gastric and duodenal neuroendocrine tumors

Endoscopy International Open ◽

10.1055/a-1119-6698 ◽

2020 ◽

Vol 08 (06) ◽

pp. E717-E721

Author(s):

Fadi Hawa ◽

Zeyad Sako ◽

Than Nguyen ◽

Andrew T. Catanzaro ◽

Eugene Zolotarevsky ◽

...

Keyword(s):

Adverse Events ◽

Neuroendocrine Tumors ◽

Endoscopic Resection ◽

Endoscopic Therapy ◽

Early Stage ◽

Type I ◽

Serious Adverse Events ◽

Duodenal Neuroendocrine Tumors

Abstract Background and study aims Endoscopic resection is recommended as initial treatment for early-stage gastric and duodenal neuroendocrine tumors (G-NETs and D-NETs). However, it can cause serious adverse events. We aimed to evaluate the efficacy and safety of the band and slough (BAS) technique as a novel and less aggressive endoscopic therapy for management of such tumors.Four patients, three diagnosed with < 10-mm D-NET and one with 10-mm type I G-NET, were treated with the BAS technique without endoscopic resection. Initial follow-up endoscopy at 3 months was done to assess for residual tumor. Subsequent endoscopic surveillance was performed. After one session of banding, all patients achieved complete remission at 3-month follow-up. No tumor recurrence was detected on repeat biopsy at 12-month surveillance endoscopy. None of the patients developed any adverse events including bleeding or perforation.The BAS technique may prove to be a safe and effective endoscopic therapy for diminutive, non-metastatic type 1 G-NETs and D-NETs. Studies of larger scale and longer follow-up periods are needed to corroborate these findings.

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Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors

Endoscopy International Open ◽

10.1055/a-0577-7546 ◽

2018 ◽

Vol 06 (08) ◽

pp. E1008-E1014 ◽

Cited By ~ 7

Author(s):

Enrique Pérez-Cuadrado-Robles ◽

Lucille Quénéhervé ◽

Walter Margos ◽

Leila Shaza ◽

Hrvoje Ivekovic ◽

...

Keyword(s):

Local Recurrence ◽

Tumor Size ◽

Endoscopic Therapy ◽

En Bloc Resection ◽

Bloc Resection ◽

R0 Resection ◽

En Bloc ◽

Delayed Bleeding ◽

Delayed Perforation

Abstract Background and study aims The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. Patients and methods This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. Results One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31 – 83, 42.7 % males) were resected by ESD (n = 37) or EMR (n = 129) and included. The median procedure time (81 vs. 50 min, P = 0.007) and tumor size (25 vs. 20 mm, P = 0.01) were higher in the ESD group. The global malignancy rate was 50.3 %. There were no differences in en-bloc resection (29.7 % vs. 44.2 %, P = 0.115), complete resection (19.4 % vs. 35.5 %, P = 0.069), and local recurrence (14.7 % vs. 16.7 %, P = 0.788) rates. Tumor size was associated with recurrence (28 vs. 20 mm, P = 0.008), with a median follow-up of 6.5 months. Focal recurrence (n = 22, 13.3 %) was treated endoscopically in 86.4 %. En-bloc resection in the ESD group was comparable in large ( ≥ 20 mm) and small lesions (27.6 % vs. 37.5 %, P = 0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4 % vs. 75 %, P < 0.001). Nine perforations were confirmed in 6 lesions (16.2 %) resected by ESD and 3 (2.3 %) by EMR (P = 0.001). Endoscopic therapy was successful in all but 1 patient (88.9 %) presenting with a delayed perforation. Conclusions ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.

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Risk of neoplastic change in large gastric hyperplastic polyps and recurrence after endoscopic resection

Endoscopy ◽

10.1055/a-1117-3166 ◽

2020 ◽

Vol 52 (06) ◽

pp. 444-453 ◽

Cited By ~ 1

Author(s):

Emmanuel Forté ◽

Bérénice Petit ◽

Thomas Walter ◽

Vincent Lépilliez ◽

Geoffroy Vanbiervliet ◽

...

Keyword(s):

Multivariate Analysis ◽

Endoscopic Resection ◽

Neoplastic Transformation ◽

R0 Resection ◽

Hyperplastic Polyps ◽

En Bloc ◽

Risk Of Recurrence ◽

Increased Risk ◽

Neoplastic Change

Abstract Background Gastric hyperplastic polyps (GHPs) have a risk of neoplastic transformation reaching 5 %. Current endoscopic resection techniques appear suboptimal with a high risk of local recurrence. This study assessed the outcomes of endoscopic resection for GHPs and identified risk factors for recurrence and neoplastic transformation. Methods This retrospective, multicenter, European study included adult patients with at least one GHP ≥ 10 mm who underwent endoscopic resection and at least one follow-up endoscopy. Patients with recurrent GHPs or hereditary gastric polyposis were excluded. All data were retrieved from the endoscopy, pathology, and hospitalization reports. Results From June 2007 to August 2018, 145 GHPs in 108 patients were included. Recurrence after endoscopic resection was 51.0 % (74 /145) in 55 patients. R0 resection or en bloc resection did not impact the risk of polyp recurrence. In multivariate analysis, cirrhosis was the only risk factor for recurrence (odds ratio [OR] 4.82, 95 % confidence interval [CI] 1.33 – 17.46; P = 0.02). Overall, 15 GHPs (10.4 %) showed neoplastic transformation, with size > 25 mm (OR 10.24, 95 %CI 2.71 – 38.69; P < 0.001) and presence of intestinal metaplasia (OR 5.93, 95 %CI 1.56 – 22.47; P = 0.01) being associated with an increased risk of neoplastic transformation in multivariate analysis. Conclusions Results confirmed the risk of recurrence and neoplastic transformation of large GHPs. The risk of neoplastic change was significantly increased for lesions > 25 mm, with a risk of high grade dysplasia appearing in polyps ≥ 50 mm. The risk of recurrence was high, particularly in cirrhosis patients, and long-term follow-up is recommended in such patients.

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UNDERWATER ENDOSCOPIC MUCOSAL RESECTION FOR SMALL RECTAL NEUROENDOCRINE TUMORS

Arquivos de Gastroenterologia ◽

10.1590/s0004-2803.202100000-37 ◽

2021 ◽

Author(s):

Lara Meireles Azeredo COUTINHO ◽

Luciano LENZ ◽

Fabio S KAWAGUTI ◽

Bruno Costa MARTINS ◽

Elisa BABA ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Neuroendocrine Tumors ◽

R0 Resection ◽

En Bloc ◽

Safe Alternative ◽

Delayed Bleeding ◽

Mucosal Resection ◽

Mean Size ◽

Deep Margin ◽

Lost To Follow Up

ABSTRACT BACKGROUND: A common site of neuroendocrine tumors (NETs) is the rectum. The technique most often used is endoscopic mucosal resection with saline injection. However, deep margins are often difficult to obtain because submucosal invasion is common. Underwater endoscopic mucosal resection (UEMR) is a technique in which the bowel lumen is filled with water rather than air, precluding the need for submucosal lifting. OBJECTIVE: This study aimed to evaluate the efficacy and safety of UEMR for removing small rectal neuroendocrine tumors (rNETs). METHODS: Retrospective study with patients who underwent UEMR in two centers. UEMR was performed using a standard colonoscope. No submucosal injection was performed. Board-certified pathologists conducted histopathologic assessment. RESULTS: UEMR for small rNET was performed on 11 patients (nine female) with a mean age of 55.8 years and 11 lesions (mean size 7 mm, range 3-12 mm). There were 9 (81%) patients with G1 rNET and two patients with G2, and all tumors invaded the submucosa with only one restricted to the mucosa. None case showed vascular or perineural invasion. All lesions were removed en bloc. Nine (81%) resections had free margins. Two patients had deep margin involvement; one had negative biopsies via endoscopic surveillance, and the other was lost to follow-up. No perforations or delayed bleeding occurred. CONCLUSION: UEMR appeared to be an effective and safe alternative for treatment of small rNETs without adverse events and with high en bloc and R0 resection rates. Further prospective studies are needed to compare available endoscopic interventions and to elucidate the most appropriate endoscopic technique for resection of rNETs.

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A133 GASTRIC ESD: PRELIMINARY EXPERIENCE IN A TERTIARY CENTER IN QUEBEC

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwab002.131 ◽

2021 ◽

Vol 4 (Supplement_1) ◽

pp. 117-118

Author(s):

D Maillet ◽

E Desilets ◽

T Maniere

Keyword(s):

Curative Resection ◽

Residual Disease ◽

High Grade Dysplasia ◽

R0 Resection ◽

Low Grade ◽

High Grade ◽

En Bloc ◽

Delayed Bleeding ◽

Tertiary Center ◽

Intramucosal Adenocarcinoma

Abstract Background Endoscopic submucosal dissection (ESD) is an endoscopic procedure developed in Asian countries to treat early gastric cancer (EGC). Western countries have less experience with this challenging technique. Aims The goal of this study is to evaluate the effectiveness of ESD as a preliminary experience. Methods This is an unicentric retrospective study of all consecutive gastric ESD for adenomas or EGC from 07/2017 to 08/2020. The primary endpoints were en bloc and R0 resection rates. Results Nineteen patients (mean age 74.2 (54–88), sex ratio 3F/16M) and 23 lesions were included. Mean diameter was 25 mm (10–90). Treatment was previously performed in 7 cases (30.4%), by ESD (5) or EMR (2). The procedure, performed under general anaesthesia, lasted on average 148 minutes (45–412). En bloc resections were performed in 16 cases (69.6%); 5 cases (21.7%) were converted to P-EMR and there was a failure to resect the lesion because of deep invasion or perforation in 2 cases (8.7%). Pathologic examination demonstrated 2 low-grade dysplasia, 4 high-grade dysplasia and 15 adenocarcinomas: intramucosal (8), sm1 (2), sm2 (2), sm3 (1) or sm deep (2). R0 and curative resection rates were 43.5% and 39.1% respectively. The complication rate related to the procedure was 30.4% including 5 perforations and 2 delayed bleeding: all were managed endoscopically. Five patients (21.7%) underwent subsequent gastrectomy for non-curative resection (4) or failed resection (1); 3 had no residual disease on final pathology, 1 had high grade dysplasia and 1 had intramucosal adenocarcinoma. One patient went to palliative care because he was unfit for surgery. Follow-up endoscopy was completed in all 17 patients who underwent endoscopic resection (mean 10 months (2–24)). Recurrence occurred in 23.5% (4/17); all were successfully treated by another ESD. Conclusions In our preliminary experience, the rate of en bloc and R0 resection were 70% and 44%. Compared to other studies, these low en bloc and curative resection rates may be explained by technically difficult lesions during the learning curve and might improve with experience. Nevertheless, surgery has been avoided in 13/19 patients (68%) with endoscopic intervention. Funding Agencies None

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Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopy ◽

10.1055/a-1442-2395 ◽

2021 ◽

Author(s):

Geoffroy Vanbiervliet ◽

Alan Moss ◽

Marianna Arvanitakis ◽

Urban Arnelo ◽

Torsten Beyna ◽

...

Keyword(s):

Endoscopic Resection ◽

En Bloc Resection ◽

Endoscopic Management ◽

Duodenal Adenoma ◽

En Bloc ◽

Strong Recommendation ◽

Delayed Bleeding ◽

Duodenal Adenomas ◽

Moderate Quality ◽

Quality Evidence

Main recommendations 1 ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2 ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3 ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4 ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5 ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.Weak recommendation, low quality evidence. 6 ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7 ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8 ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9 ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.

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Colorectal Endoscopic Submucosal Dissection in a Western Center: Analysis of Outcomes and Safety Profile

GE Portuguese Journal of Gastroenterology ◽

10.1159/000514797 ◽

2021 ◽

pp. 1-9

Author(s):

João Santos-Antunes ◽

Margarida Marques ◽

Rui Morais ◽

Fátima Carneiro ◽

Guilherme Macedo

Keyword(s):

Endoscopic Submucosal Dissection ◽

Safety Profile ◽

En Bloc Resection ◽

R0 Resection ◽

Hybrid Technique ◽

Resection Rate ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Gastrointestinal Lesions

Introduction: Endoscopic submucosal dissection (ESD) is a well-established endoscopic technique for the treatment of gastrointestinal lesions. Colorectal ESD outcomes are less reported in the Western literature, and Portuguese data are still very scarce. Our aim was to describe our experience on colorectal ESD regarding its outcomes and safety profile. Methods: We conducted a retrospective evaluation of recorded data on ESDs performed between 2015 and 2020. Only ESDs performed on epithelial neoplastic lesions were selected for further analysis. Results: Of a total of 167 colorectal ESDs, 153 were included. Technical success was achieved in 147 procedures (96%). The lesions were located in the colon (n = 24) and rectum (n = 123). The en bloc resection rate was 92% and 97%, the R0 resection rate was 83% and 82%, and the curative resection rate was 79% and 78% for the colon and the rectum, respectively. The need for a hybrid technique was the only risk factor for piecemeal or R1 resection. We report a perforation rate of 3.4% and a 4.1% rate of delayed bleeding; all the adverse events were manageable endoscopically, without the need of blood transfusions or surgery. Most of the lesions were laterally spreading tumours of the granular mixed type (70%), and 20% of the lesions were malignant (12% submucosal and 8% intramucosal cancer). Conclusion: Our series on colorectal ESD reports a very good efficacy and safety profile. This technique can be applied by endoscopists experienced in ESD.

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Anchoring the snare tip is a feasible endoscopic mucosal resection method for small rectal neuroendocrine tumors

Scientific Reports ◽

10.1038/s41598-021-92462-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Jeongseok Kim ◽

Jisup Kim ◽

Eun Hye Oh ◽

Nam Seok Ham ◽

Sung Wook Hwang ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Neuroendocrine Tumors ◽

Similar Efficacy ◽

En Bloc Resection ◽

Lesion Size ◽

Bloc Resection ◽

En Bloc ◽

Delayed Bleeding ◽

Mucosal Resection ◽

The Mean

AbstractSmall rectal neuroendocrine tumors (NETs) can be treated using cap-assisted endoscopic mucosal resection (EMR-C), which requires additional effort to apply a dedicated cap and snare. We aimed to evaluate the feasibility of a simpler modified endoscopic mucosal resection (EMR) technique, so-called anchored snare-tip EMR (ASEMR), for the treatment of small rectal NETs, comparing it with EMR-C. We retrospectively evaluated 45 ASEMR and 41 EMR-C procedures attempted on small suspected or established rectal NETs between July 2015 and May 2020. The mean (SD) lesion size was 5.4 (2.2) mm and 5.2 (1.7) mm in the ASEMR and EMR-C groups, respectively (p = 0.558). The en bloc resection rates of suspected or established rectal NETs were 95.6% (43/45) and 100%, respectively (p = 0.271). The rates of histologic complete resection of rectal NETs were 94.1% (32/34) and 88.2% (30/34), respectively (p = 0.673). The mean procedure time was significantly shorter in the ASEMR group than in the EMR-C group (3.12 [1.97] vs. 4.13 [1.59] min, p = 0.024). Delayed bleeding occurred in 6.7% (3/45) and 2.4% (1/41) of patients, respectively (p = 0.618). In conclusion, ASEMR was less time-consuming than EMR-C, and showed similar efficacy and safety profiles. ASEMR is a feasible treatment option for small rectal NETs.

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