Procedure Time for Gastric Endoscopic Submucosal Dissection according to Location, considering Both Mucosal Circumferential Incision and Submucosal Dissection

Background. Previous assessments of technical difficulty and procedure time for endoscopic submucosal dissection (ESD) of gastric neoplasms did not take into account several critical determinants of these parameters. However, two key phases of ESD determine the total procedure time: the mucosal circumference incision speed (CIS) and submucosal dissection speed (SDS). Methods. We included 302 cases of en bloc and R0 resection of gastric neoplasms performed by 10 operators who had completed the training program at our hospital. Twelve locations were classified based on multiple criteria, such as condition of surrounding mucosa, lesion vascularity, presence of submucosal fat, ulcers, scars, fibrosis, and scope and device maneuverability. Lesions in different locations were classified into three groups based on the length of the procedure: fast, moderate, or late. Results. A significant difference was found in CIS and SDS for each location (p<0.01), which demonstrates the validity of this classification system. In several locations, CIS and SDS were not consistent with each other. Conclusion. CIS and SDS did not correspond to each other even for lesions in the same location. Consideration of ESD procedure time for gastric neoplasms requires a more elaborate classification system than that previously reported.

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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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Double-endoscope assisted endoscopic submucosal dissection for treating tumors in rectum and distal colon by expert endoscopists: a feasibility study

Techniques in Coloproctology ◽

10.1007/s10151-020-02308-4 ◽

2020 ◽

Vol 24 (12) ◽

pp. 1293-1299

Author(s):

A. Ebigbo ◽

G. Tziatzios ◽

S. K. Gölder ◽

A. Probst ◽

H. Messmann

Keyword(s):

Endoscopic Submucosal Dissection ◽

Sigmoid Colon ◽

Distal Colon ◽

R0 Resection ◽

Outer Diameter ◽

Procedure Time ◽

En Bloc ◽

Submucosal Dissection ◽

Previously Treated ◽

Double Endoscope

Abstract Background Colorectal endoscopic submucosal dissection (ESD) is an effective but challenging procedure. To facilitate ESD, several methods that apply traction are available; however, the optimal one remains to be established. The aim of this study was to evaluate the feasibility and safety of the double-endoscope assisted ESD (DEA-ESD) by improving traction to treat complex colorectal lesions. Methods Naïve or previously treated lesions in the rectum and sigmoid colon were included. A grasping forceps advanced through a small-caliber endoscope (GIF-XP190N, Olympus Medical Systems, Tokyo, Japan, 5.4 mm outer diameter) was used to apply traction to the mucosal flap. Lesions were deemed complex when they exceeded a total of nine points on the SMSA scoring system (size, morphology, site, and access) and recurrent when they were previously treated with endoscopic mucosal resection (EMR). Outcome measures included procedural success, total procedure time, complications, and recurrence rate at 3-month follow-up. Results Nine patients (mean age 62.3 ± 14.5 years) were included; five had rectal and four had tumors in the sigmoid colon. The median SMSA score was 14 (SMSA Level IV—complex polyp), while three patients were pre-treated with EMR. DEA-ESD was technically feasible in all cases. En bloc resection and R0 resection rates were 100%, respectively, with a mean procedure time of 128.4 ± 54.1 min. No immediate or delayed complications occurred. Conclusions DEA-ESD is a feasible and safe method for treating complex or recurrent tumors in the rectum and distal colon.

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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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The pocket-creation method facilitates endoscopic submucosal dissection of gastric neoplasms involving the pyloric ring

Endoscopy International Open ◽

10.1055/a-1403-1153 ◽

2021 ◽

Vol 09 (07) ◽

pp. E1062-E1069

Author(s):

Masafumi Kitamura ◽

Yoshimasa Miura ◽

Satoshi Shinozaki ◽

Hirotsugu Sakamoto ◽

Yoshikazu Hayashi ◽

...

Keyword(s):

Endoscopic Submucosal Dissection ◽

Statistical Significance ◽

En Bloc Resection ◽

Pyloric Sphincter ◽

Gastric Neoplasms ◽

R0 Resection ◽

Gastric Lesions ◽

En Bloc ◽

Pyloric Ring ◽

Submucosal Dissection

Abstract Background and study aims Endoscopic submucosal dissection (ESD) of superficial gastric lesions involving the pyloric ring is difficult. The pocket-creation method (PCM) with a small-caliber-tip transparent hood can overcome this difficulty by compressing the pyloric sphincter applying both traction and counter-traction. The aim of this study is to clarify the usefulness of the PCM for ESD of superficial gastric neoplasms involving the pyloric ring compared to the conventional method (CM). Patients and methods From October 2006 to August 2019, 66 gastric lesions requiring duodenal submucosal dissection beyond the pyloric ring in 66 patients were resected. The CM was mainly performed in the first period (CM group, n = 46) and the PCM in the second period (PCM group, n = 20). We retrospectively reviewed their medical records. Results Although no significant differences were observed in en bloc resection rates between the two groups, the PCM group had a significantly higher R0 resection rate than the CM group (P = 0.047). There were no holes in resected specimens in the PCM group while three specimens in the CM group had a hole. The dissection speed in the PCM group tended to be higher than in the CM group, although it did not reach statistical significance (P = 0.148). No significant differences were observed for the incidence of adverse events. Conclusions This is the first study reporting the advantages of the PCM over the CM for ESD of gastric lesions involving the pyloric ring. We believe that the PCM is an effective strategy to compress the pyloric sphincter and facilitates R0 resection.

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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 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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Reduction in the procedure time of hybrid endoscopic submucosal dissection for early gastric neoplasms: a multi-center retrospective propensity score-matched analysis

Therapeutic Advances in Gastroenterology ◽

10.1177/1756284820939420 ◽

2020 ◽

Vol 13 ◽

pp. 175628482093942

Author(s):

Mitsuru Esaki ◽

Sho Suzuki ◽

Toshiki Horii ◽

Ryoji Ichijima ◽

Shun Yamakawa ◽

...

Keyword(s):

Propensity Score ◽

Endoscopic Submucosal Dissection ◽

Gastric Neoplasms ◽

Procedure Time ◽

Resection Rate ◽

Submucosal Dissection ◽

Absolute Indication ◽

Significant Difference ◽

Secondary Outcomes ◽

The Absolute

Background: Endoscopic submucosal dissection (ESD) for early gastric neoplasms is still a technically difficult and time-consuming procedure. Hybrid ESD (H-ESD) involves circumferential incision with partial submucosal dissection combined with subsequent mucosal resection by snaring, wherein the newly developed device allows us to perform H-ESD using a single device. This study aimed to determine the clinical outcomes of H-ESD compared with conventional ESD (C-ESD) for early gastric neoplasms. Methods: In this multi-center, retrospective study, using propensity score-matched analysis, we reviewed the charts of patients with early gastric neoplasms smaller than 20 mm treated with H-ESD or C-ESD at three hospitals between January 2017 and October 2018. The primary outcome was the procedure time, and the secondary outcomes were other factors, including the en bloc resection rate, complete resection rate, curative resection rate, and rate of adverse events. Results: Among 215 patients, 29 underwent H-ESD and 186 underwent C-ESD; 29 pairs were created by propensity score matching. In the H-ESD group, 82.8% of lesions met the absolute indication [mucosal lesions limited to 20-mm diameter, dominated by differentiated adenocarcinoma without ulcer (scar)] for endoscopic resection (ER). As a result, the procedure time of H-ESD was significantly shorter than that of C-ESD [20 (interquartile range, 12–27) min versus 40 (30–50) min; p < 0.001]. There was no significant difference in the secondary outcomes between the two groups. Conclusion: H-ESD contributed to reduced procedure time. Therefore, H-ESD could be an alternative endoscopic treatment for gastric neoplasms when the lesion fulfils the absolute indication for ER.

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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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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 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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