Effects of the combined use of a scissor-type knife and traction clip on endoscopic submucosal dissection of colorectal tumors: a propensity score-matched analysis

Abstract Background and study aims This study evaluated the technical aspects of colorectal endoscopic submucosal dissection (ESD) with the Clutch Cutter (CC) (Fujifilm Co., Tokyo, Japan), a scissor-type knife, and the S-O clip (SO) as a traction clip, and compared the safety and efficacy to ESD using a needle-type knife. Patients and methods This was a single-center retrospective study. In Study 1, we evaluated 125 ESD patients: 60 using the SO and CC (SO group) and 65 using the CC (CC group). In Study 2, we evaluated 185 ESD patients: the CC group (N = 65) and 120 using the Flush knife BT-S (Flush group) (Fujifilm Co., Tokyo, Japan). In both studies, the clinicopathological features and therapeutic outcomes were compared using a propensity score-matched analysis. Results In 36 pairs of matched patients in Study 1, the rates of en bloc resection, R0 resection, perforation, and postoperative bleeding (POB) were 97.2 %, 88.9 %, 2.8 %, and 0 %, respectively, for the SO group and 100 %, 91.7 %, 0 %, and 0 % for the CC group (not significant). The mean procedure time for the SO group among less-experienced endoscopists was significantly shorter than in the CC group (42 vs. 65 minutes, P = 0.036). In 49 pairs of matched patients in Study 2, the rates of en bloc resection, R0 resection, perforation, and POB were 100 %, 95.8 %, 0 %, and 0 %, respectively, for the CC group and 98.0 %, 95.8 %, 0 %, and 2.0 % for the Flush group (not significant). The mean procedure time in the CC group among less-experienced endoscopists was significantly shorter than in the Flush group (52 vs. 67 minutes, P = 0.038). Conclusions CC and the combined use of CC and SO reduced colorectal ESD procedure time among less-experienced endoscopists.

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A new traction method (traction ring) for colorectal endoscopic submucosal dissection: a retrospective study

10.21203/rs.3.rs-32330/v1 ◽

2020 ◽

Author(s):

Xinyuan Huang ◽

Hui-Hong Zhai ◽

Ming Ji ◽

Peng Li ◽

Yinglin Niu ◽

...

Keyword(s):

Retrospective Study ◽

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Bloc Resection ◽

R0 Resection ◽

Procedure Time ◽

En Bloc ◽

Submucosal Dissection ◽

Colorectal Endoscopic Submucosal Dissection ◽

Traction System

Abstract Background Colorectal endoscopic submucosal dissection (ESD) is a challenging operation because it is often difficult to attain good visualization of the submucosal layer. Lots of traction methods have been developed to facilitate submucosal dissection, but still not widely applied. Therefore, we designed a new traction device "traction ring". This pilot study is to evaluate if traction ring is feasible and safe for colorectal ESD. Methods We retrospectively analyzed 20 patients with colorectal lesions who had undergone traction ring assisted ESD. The main outcome was the rate of en bloc resection, R0 resection rate, procedure time, resection time, intraoperative and postoperative complications. Results The median procedure time was 74.5 min (range 35–269 min.). The median resection time was 55 min (range 25–209 min.). The application of the traction system accounting for only 2.7% of the whole procedure time. Rate of en bloc resection was 95% (19/20). Rate of R0 resections was 90% (18/20). All traction rings were successfully settled and retrieved. No serious excessive intraoperative bleeding was observed. One patient was found perforation after treatment, no further intervention was required. No delayed complications were observed within one month after the operation. Conclusions This retrospective study demonstrated that the new countertraction method (traction ring) may become a safe, effective and simple way to assist ESD for colorectal lesions.

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Balloon-assisted endoscopy facilitates endoscopic submucosal dissection of difficult superficial proximal colon tumors

Endoscopy ◽

10.1055/s-0044-100720 ◽

2018 ◽

Vol 50 (08) ◽

pp. 800-808 ◽

Cited By ~ 8

Author(s):

Takeshi Yamashina ◽

Yoshikazu Hayashi ◽

Hirotsugu Sakamoto ◽

Tomonori Yano ◽

Yoshimasa Miura ◽

...

Keyword(s):

Propensity Score ◽

Endoscopic Submucosal Dissection ◽

Postoperative Bleeding ◽

En Bloc Resection ◽

Proximal Colon ◽

Bloc Resection ◽

R0 Resection ◽

En Bloc ◽

Colon Tumors ◽

Submucosal Dissection

Abstract Background Colorectal endoscopic submucosal dissection (ESD) can be technically difficult in some situations, such as paradoxical movement of the proximal colon. The double-balloon endoscope provides stable endoscopic maneuvering, even in the small intestine. The aim of this study was to assess the outcomes of balloon-assisted endoscopic submucosal dissection (BAESD) of colonoscopically difficult superficial proximal colon tumors. Methods We retrospectively reviewed the records of patients who underwent BAESD of superficial proximal colon tumors where colonoscopic difficulties were encountered, from January 2011 to September 2016. Difficulties were defined as a previous incomplete colonoscopy using a conventional colonoscope or unstable endoscopic maneuverability around the tumor with a conventional colonoscope. A propensity score model was used as a secondary analysis to compare outcomes of the BAESD group with those of a non-BAESD group. Results BAESD was performed on 63 tumors in 63 patients. En bloc resection was achieved for 62 tumors (98 %) and an R0 resection was achieved for 55 tumors (87 %). Propensity score matching analysis created 59 matched pairs from the BAESD and non-BAESD groups. There were no statistically significant differences between the two groups in en bloc resection (100 % vs. 100 %; P > 0.99), R0 resection (90 % vs. 93 %; P = 0.74), perforation (0 % vs. 2 %; P > 0.99) or postoperative bleeding (3 % vs. 0 %; P = 0.50). Conclusion Balloon-assisted endoscopy achieved safe and reliable ESD of colonoscopically difficult superficial proximal colon tumors.

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Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe

Endoscopy International Open ◽

10.1055/a-0733-3668 ◽

2018 ◽

Vol 06 (11) ◽

pp. E1340-E1348 ◽

Cited By ~ 9

Author(s):

Carl-Fredrik Rönnow ◽

Noriya Uedo ◽

Ervin Toth ◽

Henrik Thorlacius

Keyword(s):

Learning Curve ◽

Endoscopic Submucosal Dissection ◽

Colorectal Neoplasia ◽

En Bloc Resection ◽

Bloc Resection ◽

High Rate ◽

R0 Resection ◽

En Bloc ◽

Submucosal Dissection ◽

Immediate Bleeding

Abstract Background and study aims Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results Median size was 4 cm (range 1 – 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 – 588) and median proficiency was 7.2 cm2/h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 – 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm2/h) and the last study period (10.8 cm2/h). Conclusions This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.

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Short-term outcomes following endoscopic submucosal dissection of large protruding colorectal neoplasms

Endoscopy ◽

10.1055/s-0043-123578 ◽

2017 ◽

Vol 50 (06) ◽

pp. 606-612 ◽

Cited By ~ 6

Author(s):

Taku Sakamoto ◽

Yutaka Saito ◽

Fumihiko Nakamura ◽

Seiichiro Abe ◽

Hiroyuki Takamaru ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Colorectal Neoplasms ◽

Clinical Outcomes ◽

Technical Difficulty ◽

En Bloc Resection ◽

Bloc Resection ◽

Procedure Time ◽

Short Term ◽

En Bloc ◽

Submucosal Dissection

Abstract Background Although submucosal dissection is useful for treating laterally spreading colorectal tumors, there is little information regarding the endoscopic treatment of large protruding colorectal neoplasms. Here, we aimed to evaluate the clinical outcomes of endoscopic submucosal dissection for protruding colorectal neoplasms ≥ 20 mm in diameter. Methods In total, 112 consecutive patients undergoing treatment between January 2005 and June 2017 were enrolled retrospectively. The study period was divided into six periods to evaluate any changes in outcomes over time. We reviewed all short-term clinical outcomes, including lesion characteristics, procedure time, and percentages of en bloc resection, curative resection, adverse events, and treatment discontinuation. Results The percentages of en bloc, en bloc R0, and en bloc curative resections were 88 %, 82 %, and 59 %, respectively. Perforation occurred in 11 patients (10 %), and the endoscopic procedure was discontinued in five patients (4 %) because of technical difficulty. For lesions ≥ 40 mm in diameter, the procedure time showed a statistically significant decreasing trend in the latter half of the study period. However, the rate of cure did not improve along with enhancements to the procedure’s technological aspects. Conclusions Although endoscopic submucosal dissection for large protruding lesions has advanced in terms of its technical aspects, its ability to cure large protruding neoplasms has not shown gratifying results.

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Scissor-type knife improves the safety of endoscopic submucosal dissection (ESD) among endoscopists without experience in ESD: a randomized ex vivo study

Endoscopy International Open ◽

10.1055/a-1487-5469 ◽

2021 ◽

Vol 09 (08) ◽

pp. E1207-E1213

Author(s):

Kavel Visrodia ◽

Tarek Sawas ◽

Liam Zakko ◽

Juan Reyes Genere ◽

Cadman Leggett ◽

...

Keyword(s):

Adverse Events ◽

Endoscopic Submucosal Dissection ◽

Muscle Injury ◽

Ex Vivo ◽

En Bloc Resection ◽

Bloc Resection ◽

Lower Proportion ◽

Procedure Time ◽

En Bloc ◽

Submucosal Dissection

Abstract Background and study aims Endoscopic submucosal dissection (ESD) is technically challenging, difficult to learn, and carries a substantial risk of perforation, all of which remain significant barriers to its adoptability. We aimed to determine whether use of a novel scissor-type knife improved efficacy and safety among novice performers of ESD. Materials and methods Following a brief didactic session on ESD, participants performed ESD of two lesions (2 cm diameter) in an ex vivo porcine gastric model. One resection was performed with a conventional knife and the other with the scissor knife (order of knife randomized). We recorded procedure time, successful en bloc resection, and adverse events (including full-thickness perforation and muscle injury) for each dissection. Participants completed a post-study survey. Results 10 endoscopists (8 trainees, 2 staff) considered novices in ESD participated. Compared with the conventional knife, use of the scissor knife was associated with a significantly shorter time to completion of submucosal dissection (mean 6.2 [SD 5.6] vs. 15.6 [SD 15.6] minutes; P = 0.04) and total procedure time was not significantly different (22.1 [SD 13.3] vs. 24.9 [SD 26.5] minutes; P = 0.65). Scissor knife use was also associated with a significantly lower proportion of perforation and/or muscle injury (10.0 % vs. 70.0 %; P < 0.01) and proportion of muscle injury alone (10.0 % vs. 60.0 %; P = 0.02). Conclusions Among novices performing ESD on an ex vivo animal model, use of a scissor knife was associated with a significantly lower proportion of adverse events without prolonging procedure time. Scissor-type knives may improve ESD safety, at least among novices.

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Multi-loop traction device facilitates gastric endoscopic submucosal dissection: ex vivo pilot study and an inaugural clinical experience

BMC Gastroenterology ◽

10.1186/s12876-021-02085-w ◽

2022 ◽

Vol 22 (1) ◽

Author(s):

Hiroaki Matsui ◽

Naoto Tamai ◽

Toshiki Futakuchi ◽

Shunsuke Kamba ◽

Akira Dobashi ◽

...

Keyword(s):

Pilot Study ◽

Endoscopic Submucosal Dissection ◽

Clinical Outcomes ◽

Ex Vivo ◽

En Bloc Resection ◽

Bloc Resection ◽

R0 Resection ◽

En Bloc ◽

Submucosal Dissection ◽

Traction Device

Abstract Background Endoscopic submucosal dissection (ESD) is technically difficult and requires considerable training. The authors have developed a multi-loop traction device (MLTD), a new traction device that offers easy attachment and detachment. We aimed to evaluate the utility of MLTD in ESD. Methods This ex vivo pilot study was a prospective, block-randomized, comparative study of a porcine stomach model. Twenty-four lesions were assigned to a group that undertook ESD using the MLTD (M-ESD group) and a group that undertook conventional ESD (C-ESD group) to compare the speed of submucosal dissection. In addition, the data of consecutive 10 patients with eleven gastric lesions was collected using electronic medical records to clarify the inaugural clinical outcomes of gastric ESD using MLTD. Results The median (interquartile range) speed of submucosal dissection in the M-ESD and C-ESD groups were 141.5 (60.9–177.6) mm2/min and 35.5 (20.8–52.3) mm2/min, respectively; submucosal dissection was significantly faster in the M-ESD group (p < 0.05). The rate of en bloc resection and R0 resection was 100% in both groups, and there were no perforation in either group. The MLTD attachment time was 2.5 ± 0.9 min and the MLTD extraction time was 1.0 ± 1.1 min. Clinical outcomes of MLTD in gastric ESD were almost the same as those of ex vivo pilot study. Conclusions MLTD increased the speed of submucosal dissection in ESD and was similarly effective when used by expert and trainee endoscopists without perforation. MLTD can potentially ensure a safer and faster ESD.

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Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience

Endoscopy International Open ◽

10.1055/a-1010-5663 ◽

2019 ◽

Vol 07 (12) ◽

pp. E1714-E1722

Author(s):

Dennis Yang ◽

Hiroyuki Aihara ◽

Yaseen B. Perbtani ◽

Andrew Y. Wang ◽

Abdul Aziz Aadam ◽

...

Keyword(s):

North America ◽

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Bloc Resection ◽

R0 Resection ◽

En Bloc ◽

Safety And Efficacy ◽

American Experience ◽

Submucosal Dissection ◽

Submucosal Fibrosis

Abstract Background and aims Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8–88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4–81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19–76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease.

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Treatment of Gastric Epithelial Tumours by Endoscopic Submucosal Dissection Using an Insulated-Tip Diathermic Knife

Canadian Journal of Gastroenterology ◽

10.1155/2011/135060 ◽

2011 ◽

Vol 25 (2) ◽

pp. 97-101 ◽

Cited By ~ 2

Author(s):

Xu Li Hua ◽

Qian Jun Bo ◽

Gu Liu Gen ◽

Lu Fei ◽

Wang Ya Min ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Bloc Resection ◽

Curative Treatment ◽

En Bloc ◽

Submucosal Dissection ◽

Biopsy Specimens ◽

Mean Diameter ◽

Epithelial Tumours ◽

The Mean

BACKGROUND: Endoscopic submucosal dissection (ESD) is a promising technique for the treatment of large, pre- and early malignant gastrointestinal lesions.OBJECTIVE: To assess the rates of en bloc resection, incidence of complications, procedure times and therapeutic outcomes of ESD using an insulated-tip diathermic knife; and to investigate predictors of these outcomes based on the final pathological features of biopsy specimens.METHODS: One hundred twenty patients with endoscopically suspected gastric epithelial tumours who were treated with ESD from January 2006 to December 2009 were evaluated.RESULTS: The mean diameter of the gastric epithelial tumours in the present cohort was 1.88 cm. The mean diameter of the resected specimens was 3.33 cm. The en bloc resection rate was 90% (108 of 120). The median length of the operation was 64.6 min. The bleeding and perforation complication rates were 5.0% (six of 120) and 2.5% (three of 120), respectively. Of 10 gastric tumours initially diagnosed as adenocarcinoma on biopsy, four were found to be low-grade dysplasia and six were found to be high-grade dysplasia after resection and final pathological examination. A total of 112 (93.33%) patients underwent curative treatment, eight patients (6.67%) underwent noncurative treatment with ESD, and two patients (1.67%) experienced local recurrence and subsequently underwent surgery.CONCLUSIONS: ESD is a promising local curative treatment option for gastric epithelial tumours, but still carries the risks of bleeding and/or perforation. Differences in the interpretation of histological results among different pathologists and/or between biopsy specimens before ESD and the en bloc tissue specimens after ESD will result in discrepancies.

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Endoscopic submucosal dissection of malignant non-pedunculated colorectal lesions

Endoscopy International Open ◽

10.1055/a-0602-4065 ◽

2018 ◽

Vol 06 (08) ◽

pp. E961-E968 ◽

Cited By ~ 8

Author(s):

Carl-Fredrik Rönnow ◽

Jacob Elebro ◽

Ervin Toth ◽

Henrik Thorlacius

Keyword(s):

Endoscopic Submucosal Dissection ◽

Curative Resection ◽

Residual Tumor ◽

En Bloc Resection ◽

Bloc Resection ◽

R0 Resection ◽

En Bloc ◽

Submucosal Dissection ◽

Additional Surgery ◽

Procedural Time

Abstract Background and study aims Endoscopic submucosal dissection (ESD) is an established method for en bloc resection of large non-pedunculated colorectal lesions in Asia but dissemination of ESD in Western countries is limited. The aim of this study was to evaluate the role of ESD in the management of malignant non-pedunculated colorectal lesions in a European center. Patients and methods Among 255 patients undergoing colorectal ESD between 2014 and 2016, 29 cases were identified as submucosal invasive cancers and included in this study. The main outcomes were en bloc, R0 and curative resection as well as procedural time, complications and recurrence. Results Median tumor size was 40 mm (range 20 – 70 mm). Thirteen cancers were located in the colon and 16 were located in the rectum. Procedural time was 89 minutes (range 18 – 594 minutes). Complete resection was achieved in 28 cases, en bloc and R0 resection rates were 83 % and 69 %, respectively. Curative resection rate was 38 %. One case had a perforation in the sigmoid colon requiring emergency surgery. No significant bleeding occurred. Six patients underwent additional surgery after ESD, one of whom had residual tumor. One recurrence was detected in 20 patients that were followed-up endoscopically, median follow-up time was 13 months (range 2 – 30 months). Conclusion ESD seems to be a safe and effective method for treating non-pedunculated malignant colorectal lesions after careful patient selection and proper endoscopic training.

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Endoscopic Submucosal Dissection of Gastric Neoplastic Lesions: An Italian, Multicenter Study

Journal of Clinical Medicine ◽

10.3390/jcm9030737 ◽

2020 ◽

Vol 9 (3) ◽

pp. 737

Author(s):

Raffaele Manta ◽

Giuseppe Galloro ◽

Francesco Pugliese ◽

Stefano Angeletti ◽

Angelo Caruso ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Bloc Resection ◽

R0 Resection ◽

Gastric Lesions ◽

En Bloc ◽

Submucosal Dissection ◽

Neoplastic Lesions ◽

One Year

Endoscopic submucosal dissection (ESD) allows removing neoplastic lesions on gastric mucosa, including early gastric cancer (EGC) and dysplasia. Data on ESD from Western countries are still scanty. We report results of ESD procedures performed in Italy. Data of consecutive patients who underwent ESD for gastric neoplastic removal were analyzed. The en bloc resection rate and the R0 resection rates for all neoplastic lesions were calculated, as well as the curative rate (i.e., no need for surgical treatment) for EGC. The incidence of complications, the one-month mortality, and the recurrence rate at one-year follow-up were computed. A total of 296 patients with 299 gastric lesions (80 EGC) were treated. The en bloc resection was successful for 292 (97.6%) and the R0 was achieved in 266 (89%) out of all lesions. In the EGC group, the ESD was eventually curative in 72.5% (58/80) following procedure. A complication occurred in 30 (10.1%) patients. Endoscopic treatment was successful in all 3 perforations, whereas it failed in 2 out of 27 bleeding patients who were treated with radiological embolization (1 case) or surgery (1 case). No procedure-related deaths at one-month follow-up were observed. Lesion recurrence occurred in 16 (6.2%) patients (6 EGC and 10 dysplasia). In conclusion, the rate of both en bloc and R0 gastric lesions removal was very high in Italy. However, the curative rate for EGC needs to be improved. Complications were acceptably low and amenable at endoscopy.

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