scholarly journals A121 UNDERWATER EMR FOR NON-LIFTING SESSILE COLORECTAL LESIONS

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 102-103
Author(s):  
C Galts ◽  
R Barclay ◽  
D Percy
Keyword(s):  
Surgical Resection ◽  
De Novo ◽  
Lesion Size ◽  
Colorectal Polyps ◽  
Invasive Cancer ◽  
Previous Attempt ◽  
Tubular Adenoma ◽  
En Bloc ◽  
Clinical Role ◽  
Submucosal Injection

Abstract Background Sessile colorectal lesions which do not elevate with submucosal injection — “non-lifting” lesions — are considered poor candidates for EMR due to concerns of possible invasive cancer and increased procedural risk. However, a non-lifting sign is an unreliable predictor of malignancy, relegating many benign lesions to surgical resection. Underwater EMR (UEMR), which obviates submucosal injection, is effective for sessile colorectal polyps but has not been evaluated specifically for non-lifting lesions. Aims The aim of this study was to assess the efficacy of UEMR for “non-lifting” large sessile colorectal lesions with the hypothesis that UEMR may have a clinical role in managing complex lesions. Methods We reviewed our database from 2016 to 2019 for patients referred for large (≥ 20 mm) non-lifting colorectal lesions without overt signs of invasive cancer, who subsequently underwent UEMR. Results Thirty-two cases were successfully treated with single session UEMR. 18 (56%) were de novo lesions whereas the remainder had undergone previous attempt(s) at conventional EMR. The mean lesion size was 37 ± 17 mm. 4 cases (13%) were resected en bloc; the remainder piecemeal. Final pathology was T1 adenocarcinoma, N=3 (9%); tubulovillous adenoma, N=15 (47%); tubular adenoma, N=8 (25%); sessile serrated, N=6 (19%); high-grade dysplasia, N=2 (6%). One patient with cancer underwent surgical resection (T1N0); the remainder had endoscopic follow-up over 8 ± 3 months with benign recurrent/residual lesions in 8%, all amenable to UEMR. There were no procedural complications. Conclusions In this series of large sessile non-lifting colorectal lesions, UEMR was effective for both de novo and previously treated lesions, obviating surgery in the majority of cases. Funding Agencies None

scholarly journals Endoscopic resection outcomes and predictors of failed en bloc endoscopic mucosal resection of colorectal polyps ≤ 20 mm among advanced endoscopy trainees

2021 ◽  
Vol 09 (11) ◽  
pp. E1820-E1826
Author(s):  
William W. King ◽  
Peter V. Draganov ◽  
Andrew Y. Wang ◽  
Dushant Uppal ◽  
Amir Rumman ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Endoscopic Mucosal Resection ◽  
En Bloc Resection ◽  
Lesion Size ◽  
Bloc Resection ◽  
Colorectal Polyps ◽  
Polyp Size ◽  
En Bloc ◽  
Mucosal Resection ◽  
Piecemeal Resection

Abstract Background and study aims En bloc endoscopic mucosal resection (EMR) is preferred over piecemeal resection for polyps ≤ 20 mm. Data on colorectal EMR training are limited. We aimed to evaluate the en bloc EMR rate of polyps ≤ 20 mm among advanced endoscopy trainees and to identify predictors of failed en bloc EMR. Methods This was a multicenter prospective study evaluating trainee performance in EMR during advanced endoscopy fellowship. A logistic regression model was used to identify the number of procedures and lesion cut-off size associated with an en bloc EMR rate of ≥ 80 %. Multivariate analysis was performed to identify predictors of failed en bloc EMR. Results Six trainees from six centers performed 189 colorectal EMRs, of which 104 (55 %) were for polyps ≤ 20 mm. Of these, 57.7 % (60/104) were resected en bloc. Trainees with ≥ 30 EMRs (OR 6.80; 95 % CI: 2.80–16.50; P = 0.00001) and lesions ≤ 17 mm (OR 4.56;95 CI:1.23–16.88; P = 0.02) were more likely to be associated with an en bloc EMR rate of ≥ 80 %. Independent predictors of failed en bloc EMR on multivariate analysis included: larger polyp size (OR:6.83;95 % CI:2.55–18.4; P = 0.0001), right colon location (OR:7.15; 95 % CI:1.31–38.9; P = 0.02), increased procedural difficulty (OR 2.99; 95 % CI:1.13–7.91; P = 0.03), and having performed < 30 EMRs (OR: 4.87; 95 %CI: 1.05–22.61; P = 0.04). Conclusions In this pilot study, we demonstrated that a relatively low proportion of trainees achieved en bloc EMR for polyps ≤ 20 mm and identified procedure volume and lesion size thresholds for successful en bloc EMR and independent predictors for failed en bloc resection. These preliminary results support the need for future efforts to define EMR procedure competence thresholds during training.

scholarly journals Is the Rationale of Anatomical Liver Resection for Hepatocellular Carcinoma Universally Adoptable? A Hypothesis-Driven Review

Medicina ◽  
2021 ◽  
Vol 57 (2) ◽  
pp. 131
Author(s):  
Young-Jen Lin ◽  
Cheng-Maw Ho
Keyword(s):  
Hepatocellular Carcinoma ◽  
Tumor Microenvironment ◽  
Surgical Resection ◽  
Tumor Recurrence ◽  
Hepatic Metastases ◽  
Vascular Supply ◽  
Tumor Ablation ◽  
Supporting Evidence ◽  
En Bloc ◽  
Margin Width

Surgical resection is the first-line curative treatment modality for resectable hepatocellular carcinoma (HCC). Anatomical resection (AR), described as systematic removal of a liver segment confined by tumor-bearing portal tributaries, may improve survival by reducing the risk of tumor recurrence compared with non-AR. In this article, we propose the rationale for AR and its universal adoption by providing supporting evidence from the advanced understanding of a tumor microenvironment and accumulating clinical experiences of locoregional tumor ablation therapeutics. AR may be advantageous because it completely removes the en-bloc by interrupting tumor vascular supply and thus extirpates the spreading of tumor microthrombi, if they ever exist, within the supplying portal vein. However, HCC is a hypervascular tumor that can promote neoangiogenesis in the local tumor microenvironment, which in itself can break through the anatomical boundary within the liver and even retrieve nourishment from extrahepatic vessels, such as inferior phrenic or omental arteries. Additionally, increasing clinical evidence for locoregional tumor ablation therapies, such as radiofrequency ablation, predominantly performed as a non-anatomical approach, suggests comparable outcomes for surgical resection, particularly in small HCC and colorectal, hepatic metastases. Moreover, liver transplantation for HCC, which can be considered as AR of the whole liver followed by implantation of a new graft, is not universally free from post-transplant tumor recurrence. Overall, AR should not be considered the gold standard among all surgical resection methods. Surgical resection is fundamentally reliant on choosing the optimal margin width to achieve en-bloc tumor niche removal while balancing between oncological radicality and the preservation of postoperative liver function. The importance of this is to liberate surgical resilience in hepatocellular carcinoma. The overall success of HCC treatment is determined by the clearance of the theoretical niche. Developing biomolecular-guided navigation device/technologies may provide surgical guidance toward the total removal of microscopic tumor niche to achieve superior oncological outcomes.

scholarly journals Fibrin glue: Novel submucosal injection agent for endoscopic submucosal dissection

2021 ◽  
Vol 09 (03) ◽  
pp. E319-E323
Author(s):  
Madoka Takao ◽  
Yoshitaka Takegawa ◽  
Toshitatsu Takao ◽  
Hiroya Sakaguchi ◽  
Yoshiko Nakano ◽  
...  
Keyword(s):  
Endoscopic Submucosal Dissection ◽  
Fibrin Glue ◽  
En Bloc Resection ◽  
Bloc Resection ◽  
En Bloc ◽  
Submucosal Injection ◽  
Submucosal Dissection ◽  
Vitro Model ◽  
Histopathologic Findings

Abstract Background and study aims Adequate mucosal elevation by submucosal injection is crucial for patient safety and efficiency during endoscopic submucosal dissection (ESD). This study aimed to evaluate the efficacy of fibrin glue (FG) as a long-lasting submucosal injection agent and to evaluate the technical feasibility of FG injection for ESD. Materials and methods To compare the capabilities of different agents in maintaining submucosal evaluation, we injected FG, hyaluronic acid solution, and normal saline into the porcine gastric specimen that was incised into approximately 5 × 5 cm squares. Then, we measured the height of submucosal elevations over time. Moreover, three hypothetical lesions from the resected porcine stomach underwent ESD with FG injection. Thereafter, we conducted macroscopic and histopathologic analyses. Results FG maintained the greatest submucosal elevation among all the injection agents. Three ESD procedures were performed with en bloc resection. Both macroscopic and histopathologic findings showed a thick FG clot on the ulcers. Conclusions The FG solution can be potentially used as an ESD submucosal injection agent in an in vitro model.

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

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.

ID: 3518501 EN-BLOC RESECTION RATE OF COLORECTAL POLYPS ≤ 20 MM IS LOW AMONG ADVANCED ENDOSCOPY TRAINEES

2021 ◽  
Vol 93 (6) ◽  
pp. AB70
Author(s):  
William W. King ◽  
Peter V. Draganov ◽  
Andrew Y. Wang ◽  
Dushant Uppal ◽  
Nikhil A. Kumta ◽  
...  
Keyword(s):  
En Bloc Resection ◽  
Bloc Resection ◽  
Colorectal Polyps ◽  
Resection Rate ◽  
En Bloc

scholarly journals Safety and efficacy of simultaneous colorectal ESD for large synchronous colorectal lesions

2017 ◽  
Vol 05 (07) ◽  
pp. E595-E602 ◽  
Author(s):  
Hideyuki Chiba ◽  
Jun Tachikawa ◽  
Daisuke Kurihara ◽  
Keiichi Ashikari ◽  
Toru Goto ◽  
...  
Keyword(s):  
Multiple Logistic Regression Analysis ◽  
Length Of Hospital Stay ◽  
En Bloc Resection ◽  
Lesion Size ◽  
Procedure Time ◽  
Single Group ◽  
Medical Expense ◽  
En Bloc ◽  
Sedative Drug ◽  
Simultaneous Group

Abstract Background and study aims Multiple large colorectal lesions are sometimes diagnosed during colonoscopy. However, there have been no investigations of the feasibility of simultaneous endoscopic submucosal dissection (ESD) for multiple lesions. This study aims to reveal the strategy of simultaneous ESD for multiple large colorectal lesions. Patients and methods 246 patients who underwent ESD for 274 colorectal lesions were retrospectively evaluated in this study. Fifty-one large colorectal lesions among 23 patients were treated by ESD simultaneously (simultaneous group), and 223 patients were treated with ESD for a single lesion (single group). Results En-bloc resection and curative resection rates did not differ. Compared with the single group, each procedure time was faster (31.8 ± 23.6 min vs. 45.8 ± 44.8, P = 0.002), but total procedure time was significantly longer in the simultaneous group (70.6 ± 33.4 vs. 45.8 ± 44.8 min, P = 0.01). Rates of adverse events including bleeding and perforation were not higher in the simultaneous group but the mean blood pressure, incidence of bradycardia and the amount of sedative drug used during ESD were significantly higher in the simultaneous group. Multiple logistic regression analysis identified non-experienced physician, lesion size ≥ 40 mm and submucosal fibrosis as an independent risk factor for procedure duration (≥ 90 min) (Odds ratio 11.852, 18.280, and 3.672; P < 0.05, respectively). Conclusions Simultaneous ESD for multiple synchronous colorectal lesions is safe and feasible compared with single ESD and can reduce the burden to patients, length of hospital stay and medical expense. These results need to be elucidated by further studies.

A CYC-RAD-DIV-DRIF interaction likely pre-dates the origin of floral monosymmetry in Lamiales

2021 ◽  
Author(s):  
Aniket Sengupta ◽  
Lena C. Hileman
Keyword(s):  
Evolutionary Biology ◽  
De Novo ◽  
Tomato Fruit ◽  
Regulatory Interaction ◽  
En Bloc ◽  
Regulatory Interactions ◽  
Developmental Program ◽  
Novel Traits ◽  
Carpel Development ◽  
Outstanding Question

Abstract BackgroundAn outstanding question in evolutionary biology is how genetic interactions defining novel traits evolve. They may evolve either by de novo assembly of previously non-interacting genes or by en bloc co-option of interactions from other functions. We tested these hypotheses in the context of a novel phenotype—Lamiales flower monosymmetry—defined by a developmental program that relies on regulatory interaction among CYCLOIDEA , RADIALIS , DIVARICATA , and DRIF gene products. In Antirrhinum majus (snapdragon), representing Lamiales, we tested whether components of this program likely function beyond their previously known role in petal and stamen development. In Solanum lycopersicum (tomato), representing Solanales which diverged from Lamiales before the origin of Lamiales floral monosymmetry, we additionally tested for regulatory interactions in this program. ResultsWe found that RADIALIS , DIVARICATA , and DRIF are expressed in snapdragon ovaries and developing fruit, similar to their homologs during tomato fruit development. Additionally, we found that a tomato CYCLOIDEA ortholog positively regulates a tomato RADIALIS ortholog. ConclusionOur results provide preliminary support to the hypothesis that the developmental program defining floral monosymmetry in Lamiales was co-opted en bloc from a function in carpel development. This expands our understanding of novel trait evolution facilitated by co-option of existing regulatory interactions.

Symptomatic pancreatic body endometrial cyst requiring en bloc distal pancreatectomy

2021 ◽  
Vol 14 (9) ◽  
pp. e244911
Author(s):  
Cameron Ludwig ◽  
Avery Kopacz ◽  
M Logan Warren ◽  
Edwin Onkendi
Keyword(s):  
Distal Pancreatectomy ◽  
Surgical Resection ◽  
Epigastric Pain ◽  
Rare Condition ◽  
The Body ◽  
Uneventful Recovery ◽  
En Bloc ◽  
Spleen Preserving ◽  
Robotic Resection ◽  
Endometrial Cyst

Pancreatic endometriosis is an extremely rare condition, with only a few cases described in the literature. Definitive diagnosis is often difficult to elucidate and will almost always require biopsy or surgical resection. We present a case of a female in her early thirties with a well-known history of widespread endometriosis presenting with vague epigastric pain. CT imaging showed an 11 cm well-circumscribed simple-appearing cyst in the lessor sac. Its origin could not be determined preoperatively but it appeared to involve the parenchyma of the body of the pancreas. Due to the associated pain and indeterminate nature, subtotal surgical resection of the extrapancreatic cyst was performed with the intrapancreatic cyst being managed by a cystogastrostomy to the adjacent stomach in a planned pancreas-sparing procedure following intraoperative confirmation it was arising within the pancreas. Pathological evaluation of the resected cyst confirmed it to be an endometrial cyst. The cystogastrostomy anastomosis subsequently obstructed a few weeks postoperatively and symptoms recurred from cyst enlargement. Redo robotic resection with resection of the remnant cyst, cystogastrostomy and en bloc spleen-preserving distal pancreatectomy was performed. The patient had an uneventful recovery. She has had no recurrence of cyst or symptoms since. A procedure video is included in the report.

scholarly journals Piecemeal resection of 20- to 25-mm colorectal polyps necessitates short-term surveillance colonoscopy to reduce local recurrence similar to en bloc removal

2020 ◽  
Vol 92 (6) ◽  
pp. 1276-1277 ◽  
Author(s):  
Kenichiro Imai ◽  
Kinichi Hotta ◽  
Sayo Ito ◽  
Yuichiro Yamaguchi ◽  
Yoshihiro Kishida ◽  
...  
Keyword(s):  
Local Recurrence ◽  
Colorectal Polyps ◽  
Surveillance Colonoscopy ◽  
Short Term ◽  
En Bloc ◽  
Piecemeal Resection

scholarly journals Review of de novo cerebral arteriovenous malformation: haemorrhage risk, treatment approaches and outcomes

2018 ◽  
Vol 31 (3) ◽  
pp. 224-229 ◽  
Author(s):  
Xianli Lv ◽  
Guihuai Wang
Keyword(s):  
Arteriovenous Malformation ◽  
Surgical Resection ◽  
De Novo ◽  
Cerebral Arteriovenous Malformation ◽  
Morbidity And Mortality ◽  
Treatment Approaches ◽  
Haemorrhage Risk ◽  
Number Of Patients ◽  
Pubmed Database ◽  
Risk Treatment

Objective A small number of patients has been reported to develop a completely new or de novo arteriovenous malformation (AVM) after brain surgery, haemorrhage, head trauma or ischaemic stroke. The natural history of these lesions is unknown. In this review, both ruptured and unruptured de novo AVMs and their treatments were reviewed. Methods Published literature in the PubMed database citing ‘de novo cerebral arteriovenous malformation’ was reviewed. Additional studies were identified through reference searches in each reviewed article. A review was performed using all published cases, the treatment approaches and outcomes. Results A total of 38 patients, including 37 de novo AVMs reported from 1988 to 17 November 2017 and our one patient, was collected. The age at AVM diagnosis was 5–73 years (mean ± SD, 27.6 ± 20.5 years). The duration time, from negative examination to AVM diagnosis, was 2 months to 25 years (mean ± SD, 6.6 ± 4.9 years). The presentation of de novo AVM was headaches in three (7.9%) patients, bleedings in 12 (31.6%), incidental in 14 (36.8%) and seizure in nine (23.7%). The estimated risk of haemorrhage was 4.8% per year. Seventeen (44.7%) patients were treated with surgical resection, 10 (26.3%) were conservatively observed, nine (23.7%) were treated with radiosurgery and two (5.3%) were endovascularly embolised. The morbidity and mortality were reported as 5.3% and 7.9%, respectively. Conclusion Post-natal de novo AVMs have been reported. Their annual haemorrhage risk is 4.8%. Most of them are treated by surgical resection and are associated with morbidity and mortality.

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