Endoscopic submucosal dissection of colitis-related dysplasia

Abstract Background and study aims Endoscopic submucosal dissection (ESD) offers en bloc resection of lesions, allowing precise pathological assessment. Although possible in ulcerative colitis (UC) patients, the chronic inflammation may increase the procedural risks and reduce the complete resection rate. The aim of this study was to assess the feasibility of ESD for UC and to consider the factors contributing to its technical difficulty. Patients and methods Multicenter experiences of ESD for UC were retrospectively analyzed by reviewing endoscopic videos, pictures, reports, and clinical notes. Results A total of 32 dysplastic lesions were included (23 in British patients, 9 in Japanese patients). The lesions were macroscopically flat or with subtle extension macroscopically in 30 patients (94 %), with a median size of 33 mm (range 12 – 73 mm), and were located in the distal colon, including one on a pouch anastomosis. Submucosal fibrosis and adipose deposition were observed in 31 (97 %) and 13 lesions (41 %), respectively. En bloc resection was possible in 29/32 lesions (91 %). One patient had delayed bleeding. Advanced pathology was observed in 11 lesions (35 %). Recurrence was observed in only one patient (after a median of 33 months [range 6 – 76 months]); however, three patients developed metachronous lesions. Conclusions ESD is feasible for UC dysplasia without an increased rate of complications. Submucosal fibrosis and fat deposition were frequently observed and contributed to the technical complexity. Careful and intensive follow-up should be organized to detect metachronous lesions.

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The pocket-creation method may facilitate endoscopic submucosal dissection of large colorectal sessile tumors

Endoscopy International Open ◽

10.1055/a-1190-7880 ◽

2020 ◽

Vol 08 (08) ◽

pp. E1021-E1030

Author(s):

Takeshi Yamashina ◽

Yoshikazu Hayashi ◽

Hisashi Fukuda ◽

Masahiro Okada ◽

Takahito Takezawa ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Primary Outcome Measure ◽

Bloc Resection ◽

R0 Resection ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Significant Difference ◽

Submucosal Fibrosis

Abstract Background and study aims Resecting large colorectal sessile tumors using endoscopic submucosal dissection (ESD) is challenging because of severe submucosal fibrosis. Previously, we reported that ESD strategy using the pocket-creation method (PCM) is useful for large colorectal sessile tumors, but there are no large studies reporting the effectiveness and safety of the PCM for resection of large colorectal sessile tumors. Patients and methods This was a retrospective review of 90 large colorectal sessile tumors in 89 patients who underwent ESD in our institution. Large colorectal sessile tumors were defined as polypoid lesions 20 mm or more in diameter. We divided them into PCM (n = 40) and conventional method (CM) groups (n = 50). The primary outcome measure was en bloc resection. The inverse-probability-treatment weighting (IPTW) approach was used to adjust for selection bias. Results Both PCM and CM achieved high en bloc resection (100 % vs. 94 %, non-adjusted P = 0.25, IPTW-adjusted P = 0.19) and R0 resection rates (88 % vs. 78 %, non-adjusted P = 0.28, IPTW-adjusted P = 0.27). When PCM was used, the rate of pathologically negative vertical margins was significantly greater than with the CM (IPTW-adjusted P = 0.045). The dissection time was significantly shorter (IPTW-adjusted P = 0.025) and dissection speed faster (IPTW-adjusted P = 0.013) using the PCM than when the CM was used. There was no significant difference in the incidence of adverse events (intraprocedural perforation and delayed bleeding, IPTW-adjusted P = 0.68). Conclusion Although en bloc resection and R0 resection rates were similar, PCM significantly increased the rate of negative vertical margins with rapid dissection for treatment of large colorectal sessile tumors.

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Preoperative endoscopic predictors of severe submucosal fibrosis in colorectal tumors undergoing endoscopic submucosal dissection

Endoscopy International Open ◽

10.1055/a-0848-8225 ◽

2019 ◽

Vol 07 (04) ◽

pp. E421-E430 ◽

Cited By ~ 4

Author(s):

Uayporn Kaosombatwattana ◽

Takeshi Yamamura ◽

Julajak Limsrivilai ◽

Masanao Nakamura ◽

Somchai Leelakusolvong ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Curative Resection ◽

Significant Risk ◽

En Bloc Resection ◽

Bloc Resection ◽

Resection Rate ◽

En Bloc ◽

Submucosal Dissection ◽

Submucosal Fibrosis ◽

Severe Fibrosis

Abstract Background and study aims Endoscopic submucosal dissection (ESD) enables en bloc removal of colorectal neoplasms regardless of size. Submucosal fibrosis is a significant factor for technical difficulty and poor outcomes. We assessed the predictive factors for severe submucosal fibrosis and the ESD outcomes. Patients and methods Patients undergoing ESD from January 2006 to September 2017 were retrospectively reviewed. The degree of submucosal fibrosis was classified into three types: no fibrosis (F0), mild fibrosis (F1), and severe fibrosis (F2). F0 and F1 cases were grouped as non-severe fibrosis for comparison with the severe fibrosis group. Predictors of severe submucosal fibrosis and ESD outcomes were evaluated. Results ESD was performed in 524 lesions (60 % male; mean age, 67.8 years). Eighty lesions with severe fibrosis (15.3 %) were observed. The overall en bloc resection rate and curative resection rate were 94.3 % and 77.7 %, respectively. Rates of en bloc resection (91.2 % vs. 94.8 %, P = 0.2) and perforation (7.5 % vs. 5.6 %, P = 0.45) were no different between severe fibrosis and non-severe fibrosis groups. However, incidences of non-curative resection and low resection speed were significantly higher in the severe fibrosis group. Among protruding lesions, tumor height and volume were significantly greater in the severe counterparts. A diameter ≥ 40 mm, endoscopic finding of the tumor beyond fold, and fold convergence were independent risk factors for severe fibrosis. Conclusions Severe submucosal fibrosis is a significant risk factor for non-curative resection and a long procedural time. Tumor size and morphology might help to predict the severity of fibrosis.

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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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Usefulness of a multifunctional snare designed for colorectal hybrid endoscopic submucosal dissection (with video)

Endoscopy International Open ◽

10.1055/s-0043-124364 ◽

2018 ◽

Vol 06 (02) ◽

pp. E249-E253 ◽

Cited By ~ 12

Author(s):

Ken Ohata ◽

Takashi Muramoto ◽

Yohei Minato ◽

Hideyuki Chiba ◽

Eiji Sakai ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Therapeutic Option ◽

Cost Effective ◽

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Tumors ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Needle Knife

AbstractSince colorectal endoscopic submucosal dissection (ESD) remains technically difficult, hybrid ESD was developed as an alternative therapeutic option to achieve en bloc resection of relatively large lesions. In this feasibility study, we evaluated the safety and efficacy of hybrid colorectal ESD using a newly developed multifunctional snare. From June to August 2016, we prospectively enrolled 10 consecutive patients with non-pedunculated intramucosal colorectal tumors 20 – 30 mm in diameter. All of the hybrid ESD steps were performed using the “SOUTEN” snare. The knob-shaped tip attached to the loop top helps to stabilize the needle-knife, making it less likely to slip during circumferential incision and enables partial submucosal dissection. All of the lesions were curatively resected by hybrid ESD, with a short mean procedure time (16.1 ± 4.8 minutes). The mean diameters of the resected specimens and tumors were 30.5 ± 4.9 and 26.0 ± 3.5 mm, respectively. No perforations occurred, while delayed bleeding occurred in 1 patient. In conclusion, hybrid ESD using a multifunctional snare enables easy, safe, and cost-effective resection of relatively large colorectal tumors to be achieved.Study registration: UMIN000022545

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Risk Factors for Technical Difficulty of Endoscopic Submucosal Dissection in Colorectal Tumors: A Case Series and Meta-Analysis

10.21203/rs.3.rs-33610/v1 ◽

2020 ◽

Author(s):

Yan Gao ◽

Wei Jiang ◽

Hui-Hong Zhai ◽

Jianing Xu ◽

Shanshan Wu ◽

...

Keyword(s):

Risk Factors ◽

Endoscopic Submucosal Dissection ◽

Meta Analysis ◽

Dentate Line ◽

En Bloc Resection ◽

Bloc Resection ◽

En Bloc ◽

Submucosal Dissection ◽

Submucosal Fibrosis ◽

Lifting Sign

Abstract Background and Aims: Endoscopic submucosal dissection has become widely accepted as an efficient and well-established option for colorectal neoplastic lesions (CRNs). However, there are still some barriers for endoscopists that hinder the successful ESD. The current study was to evaluate risk factors for the failure of en-bloc resection in the colorectal endoscopic submucosal dissection (ESD).Methods: A retrospective chart review was performed from patients who underwent ESD for colorectal neoplasms (CRNs) between January 2015 and April 2017. The demographics and colonoscopic reports were analyzed. A meta-analysis was conducted for the risk factors for the failure of en-bloc or R0 resection. Results: 253 ESD cases were completed in en-bloc resection. Ulcerative colitis, previous abdominal surgeries, lesions on the Bauhin’s valve/ dentate line, non-lifting sign and submucosal fibrosis were associated with the failure of en-bloc resection (P<0.05). Meta-analysis showed that laterally spreading tumors, tumor larger than 40mm, Bauhin’s valve/dentate line, flexure, non-lifting sign, and submucosal fibrosis were the factors for the failure of en bloc or R0 resection. The rates of perforation were obviously higher in N-EBR groups compared to EBR groups. No significant results can be observed on the local recurrence based on these studies. Conclusions: Preoperative factors such as laterally spreading tumors, tumor larger than 40mm, Bauhin’s valve/dentate line, flexure and intraoperative factors such as non-lifting sign, submucosal fibrosis should be put more focus to reach better outcomes in CRNs patients.

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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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Usefulness of epinephrine-added injection solution to reduce procedure time for gastric endoscopic submucosal dissection

Endoscopy International Open ◽

10.1055/a-1192-4202 ◽

2020 ◽

Vol 08 (08) ◽

pp. E1044-E1051

Author(s):

Shuntaro Inoue ◽

Noriya Uedo ◽

Takahiro Tabuchi ◽

Kentaro Nakagawa ◽

Masayasu Ohmori ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Bloc Resection ◽

Tumor Type ◽

Procedure Time ◽

Injection Solution ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Significant Difference

Abstract Background and study aims Epinephrine-added submucosal injection solution is used to facilitate hemostasis of non-variceal upper gastrointestinal bleeding and to prevent delayed bleeding of large pedunculated colorectal lesions. However, its benefit in gastric endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unclear. The effectiveness of epinephrine-added injection solution for outcomes of gastric ESD was examined using propensity score matching analysis. Patients and methods A total of 1,599 patients with solitary EGC (83 with non-epinephrine-added solution and 1,516 with epinephrine-added solution) between 2011 and 2018 were enrolled. Propensity scores were calculated to balance the distribution of baseline characteristics: age, sex, tumor location, specimen size, presence of ulcer scar, tumor depth, histological tumor type, and operators’ experience, and 1:3 matching was performed. En bloc resection rate, mean procedure time, delayed bleeding rate, and perforation rate were compared between the non-epinephrine (n = 79) and epinephrine (n = 237) groups. Results Mean procedure time was significantly shorter in the epinephrine group than in the non-epinephrine group (60 vs. 78 min, P < 0.001). No significant difference was found in the rate of en bloc resection (both 99 %), incidence of delayed bleeding (both 6 %), or perforation (0 vs. 0.8 %) between the two groups. In multiple linear regression analysis, use of epinephrine-added solution was independently associated with short procedure time (P < 0.001) after adjustment for other covariates. Conclusion The results suggest that epinephrine-added injection solution is useful for reduction of gastric ESD procedure time, warranting validation in a randomized controlled trial.

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Proton Pump Inhibitor Therapy before and after Endoscopic Submucosal Dissection: A Review

Diagnostic and Therapeutic Endoscopy ◽

10.1155/2012/791873 ◽

2012 ◽

Vol 2012 ◽

pp. 1-11 ◽

Cited By ~ 10

Author(s):

Mitsushige Sugimoto ◽

Jin Seok Jang ◽

Yashiro Yoshizawa ◽

Satoshi Osawa ◽

Ken Sugimoto ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Proton Pump ◽

En Bloc Resection ◽

Bloc Resection ◽

Proton Pump Inhibitor Therapy ◽

Acid Inhibition ◽

Cyp2c19 Genotype ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection

Endoscopic submucosal dissection (ESD) is a novel endoscopic procedure first developed in the 1990s which enables en bloc resection of gastric neoplastic lesions that are difficult to resect via conventional endoscopic mucosal resection. However, given that ESD increases the risk of intra- and post-ESD delayed bleeding and that platelet aggregation and coagulation in artificial ulcers after ESD strongly depend on intragastric pH, faster and stronger acid inhibition via proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H2RAs) as well as endoscopic hemostasis by thermocoagulation during ESD have been used to prevent ESD-related bleeding. Because PPIs more potently inhibit acid secretion than H2RAs, they are often the first-line drugs employed in ESD treatment. However, acid inhibition after the initial infusion of a PPI is weaker in the early phase than that achievable with H2RAs; further, PPI effectiveness can vary depending on genetic differences in CYP2C19. Therefore, optimal acid inhibition may require tailored treatment based on CYP2C19 genotype when ESD is performed, with a concomitant infusion of PPI and H2RA possibly most effective for patients with the rapid metabolizer CYP2C19 genotype, while PPI alone may be sufficient for those with the intermediate or poor metabolizer genotypes.

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Prophylactic clip closure may reduce the risk of delayed bleeding after colorectal endoscopic submucosal dissection

Endoscopy International Open ◽

10.1055/a-0581-8886 ◽

2018 ◽

Vol 06 (05) ◽

pp. E582-E588 ◽

Cited By ~ 9

Author(s):

Hideharu Ogiyama ◽

Shusaku Tsutsui ◽

Yoko Murayama ◽

Shingo Maeda ◽

Shin Satake ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

En Bloc Resection ◽

Bloc Resection ◽

En Bloc ◽

Exact Test ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Student’S T ◽

Closure Group ◽

Clip Closure

Abstract Background and study aims Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large superficial colorectal tumors, but delayed bleeding remains one of the most common complications of colorectal ESD. The aim of the present study was to evaluate the clinical efficacy of prophylactic clip closure of mucosal defects for the prevention of delayed bleeding after colorectal ESD. Patients and methods We enrolled consecutive patients with colorectal lesions between January 2012 and May 2017 in this retrospective study. In the early part of this period, post-ESD mucosal defects were not closed (non-closure group); however, from January 2014, post-ESD mucosal defects were prophylactically closed with clips when possible (closure group). The main outcome measured was delayed bleeding. Variables were analyzed using the chi-squared test, Fisher’s exact test, or Student’s t-test. Results Of 156 lesions analyzed, 61 were in the non-closure group and 95 in the closure group. Overall, delayed bleeding occurred in 5 cases (3.2 %). The delayed bleeding rate was 0 % (0/95) in the closure group and 8.2 % (5/61) in the non-closure group (P = 0.008). The mean procedure time for closure was 10.4 ± 4.6 min (range 3 – 26 min). Conclusions We demonstrated that prophylactic clip closure of mucosal defects might reduce the risk of delayed bleeding after colorectal ESD.

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Predictive factors of submucosal fibrosis before endoscopic submucosal dissection for superficial squamous esophageal neoplasia.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.41 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 41-41

Author(s):

Byung Wook Kim

Keyword(s):

Endoscopic Submucosal Dissection ◽

Predictive Factors ◽

Complication Rate ◽

En Bloc Resection ◽

Bloc Resection ◽

Initial Diagnosis ◽

En Bloc ◽

Esophageal Neoplasia ◽

Submucosal Dissection ◽

Submucosal Fibrosis

41 Background: Endoscopic submucosal dissection (ESD) is an effective treatment modality for superficial squamous esophageal neoplasia (SSEN). However, submucosal fibrosis is an important obstacle to successful ESD. The aim of this study was to determine the ESD outcome in relationship to the degree of submucosal fibrosis of SSEN and to identify factors for predicting submucosal fibrosis. Methods: We retrospectively analyzed endoscopic and pathologic factors related to submucosal fibrosis in 41 patients with SSEN who underwent ESD. Also, en bloc resection, complication rate, and procedure time according to the degree of submucosal fibrosis were evaluated. Masson’s trichrome staining was used to evaluate histologic submucosal fibrosis. Results: A depressed type tumor (vs. nondepressed type tumor, P= 0.002), longer diameter of tumor greater than 20 mm (vs. longer diameter of tumor ≤ 20mm, P= 0.036), and delayed ESD after initial diagnosis (vs. immediate ESD after initial diagnosis, P= 0.005) were independent factors predictive of submucosal fibrosis. The severity of submucosal fibrosis was significantly associated with a higher complication rate such as bleeding and perforation. Also, as the severity of the submucosal fibrosis increased, the amount of time required for the ESD procedure increased. Conclusions: Longer diameter of tumor greater than 20 mm and macroscopic depression are endoscopic predictive factors of submucosal fibrosis in SSEN. Moreover, to avoid submucosal fibrosis, ESD should be attempted immediately after biopsy for the diagnosis of SSEN.

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