Endoscopic Submucosal Dissection Outcomes for Gastroesophageal Tumors in Low Volume Units: A Multicenter Survey

Background and Aims. Endoscopic submucosal dissection (ESD) outcomes have traditionally been reported from high volume centers in East Asia. Data from low volume centers in other parts of Asia remain sparse. Methods. A retrospective survey with a structured questionnaire of 5 tertiary centers in 3 countries in South East Asia was conducted. Details of training and clinical outcomes of ESD cases, with follow-up data from these centers, were analyzed. Results. Seven endoscopists from the 5 centers performed a total of 35 cases of ESD in the upper gastrointestinal tract (UGIT) over a 6-year duration. Details of the lesions excised were as follows: median size was 20 mm, morphologically 20 (68.6%) were flat/depressed and 6 (17.1%) were submucosal, and histologically 27 (77.1%) were neoplastic. The median duration of ESD procedures was 105 minutes, with an en-bloc resection rate of 91.4%. There was 1 (2.9%) case of delayed bleeding, but no perforation nor mortality in any of the cases. The recurrence rate after ESD was 5.7%. A prolonged ESD duration was influenced by a larger size of lesion (25 mm, p=0.02) but not by factors related to the training experience of endoscopists. Conclusions. ESD in the UGIT is feasible and safe in low volume centers in Asia.

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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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Endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: short- to long-term outcomes

Endoscopy ◽

10.1055/s-0043-113631 ◽

2017 ◽

Vol 49 (09) ◽

pp. 913-918 ◽

Cited By ~ 14

Author(s):

Toshio Kuwai ◽

Toshiki Yamaguchi ◽

Hiroki Imagawa ◽

Yuki Sumida ◽

Takeshi Takasago ◽

...

Keyword(s):

Survival Rate ◽

Endoscopic Submucosal Dissection ◽

Colorectal Neoplasms ◽

En Bloc Resection ◽

Long Term Outcomes ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Short And Long Term

Abstract Background and study aims Endoscopic submucosal dissection (ESD) for colorectal neoplasms remains challenging because of technical issues imposed by the complex anatomical features of the large intestine. We evaluated the feasibility, and the short- and long-term clinical outcomes of ESD for early colorectal neoplasms performed using the Stag-beetle Knife Jr. (SB Knife Jr.) Patients and methods We retrospectively assessed 228 patients who underwent ESD for 247 colorectal lesions with the SB Knife Jr. Clinicopathological characteristics of the neoplasms, complications, and various short- and long-term outcomes were evaluated. Results Mean tumor size was 34.3 mm and median procedure time was 76 minutes. The SB Knife Jr. achieved 98.4 % en bloc resection, 93.9 % complete resection, and 85.4 % curative resection. No perforations occurred during the procedure, and a delayed bleeding rate of 2.4 % was observed. Long-term outcomes were favorable with no distant recurrence, 1.1 % local recurrence, a 5-year overall survival rate of 94.1 % and 5-year tumor-specific survival rate of 98.6 % in patients with cancer. Conclusions ESD using the SB Knife Jr. is technically efficient and safe in treating early colorectal neoplasms and is associated with favorable short- and long-term outcomes.

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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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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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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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A new procedure combining local resection with endoscopic submucosal dissection for low rectal tumor: a four-case series

Endoscopy International Open ◽

10.1055/a-1038-3973 ◽

2020 ◽

Vol 08 (02) ◽

pp. E214-E220

Author(s):

Naoki Asayama ◽

Shinji Nagata ◽

Masashi Miguchi ◽

Kenjiro Shigita ◽

Taiki Aoyama ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Case Series ◽

En Bloc Resection ◽

Rectal Tumor ◽

Local Resection ◽

Rectal Tumors ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Tumors ◽

Submucosal Dissection

AbstractRectal tumors are traditionally resected by proctectomy to ensure the achievement of negative margins, an approach associated with an adverse impact on subsequent quality of life due to sequelae such as permanent stoma and urinary and sexual dysfunction. Many studies have now demonstrated that recurrence after local excision of early rectal tumors is significantly higher than would typically be expected. We have developed a new procedure, described herein, that combines local resection with endoscopic submucosal dissection for low rectal tumor. We report four consecutive cases (three submucosal tumors and one tumor with clinical deep submucosal invasion) treated at Hiroshima City Asa Citizens Hospital between January 2009 and March 2018. The mean duration of the procedure was 137 minutes. The en bloc resection and histologically complete resection rates were 100 %. Delayed bleeding and perforation rates were 0 %. Postoperative complications were fever and anal pain (one case each). All patients recovered with conservative therapy. No recurrence was found in any of the four patients during a follow-up period of 56 months. Our combined endoscopic and surgical procedure for low rectal tumors enabled definite negative vertical margins, reduced tumor volume, allowed for accurate pathological diagnosis, preserved rectal function, and aided the decision on additional therapy.

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Endoscopic submucosal dissection of colitis-related dysplasia

Endoscopy ◽

10.1055/s-0043-114410 ◽

2017 ◽

Vol 49 (12) ◽

pp. 1237-1242 ◽

Cited By ~ 21

Author(s):

Noriko Suzuki ◽

Takashi Toyonaga ◽

James East

Keyword(s):

Endoscopic Submucosal Dissection ◽

Technical Difficulty ◽

Distal Colon ◽

Japanese Patients ◽

En Bloc Resection ◽

Bloc Resection ◽

En Bloc ◽

Delayed Bleeding ◽

Submucosal Dissection ◽

Submucosal Fibrosis

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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Acceptability of endoscopic submucosal dissection for sessile serrated lesions: comparison with non-sessile serrated lesions

Endoscopy International Open ◽

10.1055/a-1268-7353 ◽

2020 ◽

Vol 08 (12) ◽

pp. E1832-E1839

Author(s):

Yuichiro Kuroki ◽

Toshiyuki Endo ◽

Kenta Iwahashi ◽

Naoki Miyao ◽

Reika Suzuki ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Postoperative Bleeding ◽

En Bloc Resection ◽

Tumor Location ◽

Proximal Colon ◽

R0 Resection ◽

Resection Rate ◽

En Bloc ◽

Submucosal Dissection ◽

Serrated Lesions

Abstract Background and study aims Sessile serrated lesions (SSL) are major precursor lesions of serrated pathway cancers, and appropriate treatment may prevent interval colorectal cancer. Studies have reported the outcomes of endoscopic mucosal resection (EMR) for SSL; however, there are insufficient reports on endoscopic submucosal dissection (ESD). We examined the characteristics and outcomes of SSL and compared them to those of non-SSL in ESD. Patients and methods We reviewed 370 consecutive cases in 322 patients who underwent colorectal ESD between January 2016 and March 2020 at our hospital. There were 267 0-IIa lesions that were stratified into 41 SSL and 226 non-SSL (intramucosal cancer, adenoma) cases. We used propensity matching to adjust for the variances in the factors affecting treatment between the SSL and non-SSL groups. Results In the baseline cases, young women and proximal colon tumor location were significantly more common in the SSL group. There were no statistically significant differences between the SSL and non-SSL groups in terms of en bloc resection rate (97.6 % vs. 99.6 %; P = 0.28), R0 resection rate (92.7 % vs. 93.4 %; P = 0.74), perforation (0 % vs. 0.9 %; P > 0.99), and postoperative bleeding (2.4 % vs. 1.8 %; P = 0.56). Thirty-eight pairs were matched using propensity score, and the median dissection speed (12 vs. 7.7 cm2/h; P = 0.0095) was significantly faster in the SSL than in the non-SSL group. Conclusions ESD for SSL was safely performed, and SSL was smoother to remove than non-SSL. ESD might be an acceptable endoscopic treatment option for SSL.

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