The introduction of colorectal endoscopic submucosal hydrodissection at a Western Center: results and learning curve

Abstract Background Colorectal endoscopic submucosal dissection (CR-ESD) is an evolving technique in Western countries. The use of hydrodissection has been established as an effective technique for safe resection. However, it is unknown if the adoption of this technique can help a novice perform ESD safely without prior experience or formal tutorial. Here we aimed to determine the results of the introduction of endoscopic submucosal hydrodissection for the treatment of complex colorectal polyps and establish the learning curve for this technique, at a European tertiary hospital. Methods This study included data from 80 consecutive CR-ESDs performed for complex colorectal polyps, by a single endoscopist within a structured training program. The main outcome was en bloc resection rate, while secondary outcomes included complications (perforation and bleeding), knife en bloc (KEB) resection rate, knife-snare en bloc resection rate, conversion rate to endoscopic piecemeal mucosal resection (EPMR), complete resection rate, curative resection rate. To explore the impact of experience, procedures were divided into 4 groups of 20 each, with outcomes measures compared between these. Results The overall en bloc resection rate was 75%. KEB resection was obtained in 15%, 25%, 50%, and 80% cases in the consecutive periods (period 1 vs 4, p<0.001; periods 1, 2 and 3 vs 4, p<0.001). Conversion rate to EPMR was obtained in 40%, 25%, 25% and 5% respectively (period 1,2 and 3 vs 4; p=0.031). Curative resection was achieved in 55%, 75%, 70% and 95% respectively (p=0.037). Series results were 75% R0 resection, 23.7% conversion to EPMR, and 1.2% incomplete resection. Complications included perforations (7.5%) and bleeding (3.75%), there was no significant difference in the 4 periods of training. Multivariate analysis revealed factors more likely to result in non-en bloc versus en bloc resection were polyp size > 35 mm [70% vs. 23.4%; OR 13.2 (95% CI: 1.7-100.9); p=0. 013], severe fibrosis [40% vs. 11.7%; OR 10.2 (95% CI: 1.2-86.3); p= 0.033] and non-use of CO2 [65% vs. 30%; OR 0.09 (95% CI: 0.01-0.53); p= 0.008]. Conclusions CR-ESD by hydrodissection can be implemented in a western centre and offers safe and effective treatment for complex polyps.

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

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2021.03.192 ◽

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

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Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial

BMC Gastroenterology ◽

10.1186/s12876-020-01457-y ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Zhixin Zhang ◽

Yonghong Xia ◽

Hongyao Cui ◽

Xin Yuan ◽

Chunnian Wang ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Polyps ◽

Efficacy And Safety ◽

Resection Rate ◽

En Bloc ◽

Randomized Controlled ◽

Mucosal Resection ◽

Group 1

Abstract Background Underwater endoscopic mucosal resection (UEMR) is a recently developed technique and can be performed during water-aided or ordinary colonoscopy for the treatment of colorectal polyps. The objective of this clinical trial was to evaluate the efficacy and safety of UEMR in comparison with conventional endoscopic mucosal resection (CEMR) of small non-pedunculated colorectal polyps. Methods Patients with small size, non-pedunculated colorectal polyps (4–9 mm in size) who underwent colonoscopic polypectomy were enrolled in this multicenter randomized controlled clinical trial. The patients were randomly allocated to two groups, an UEMR group and a CEMR group. Efficacy and safety were compared between groups. Results In the intention-to-treat (ITT) analysis, the complete resection rate was 83.1% (59/71) in the UEMR group and 87.3% (62/71) in the CEMR group. The en-bloc resection rate was 94.4% (67/71) in the UEMR group and 91.5% (65/71) in the CEMR group (difference 2.9%; 90% CI − 4.2 to 9.9%), showed noninferiority (noninferiority margin − 5.7% < − 4.2%). No significant difference in procedure time (81 s vs. 72 s, P = 0.183) was observed. Early bleeding was observed in 1.4% of patients in the CEMR group (1/71) and 1.4% of patients in the UEMR group (1/71). None of the patients in the UEMR group complained of postprocedural bloody stool, whereas two patients in the CEMR group (2/64) reported this adverse event. Conclusion Our results indicate that UEMR is safer and just as effective as CEMR in En-bloc resection for the treatment of small colorectal polyps as such, UEMR is recommended as an alternative approach to excising small and non-pedunculated colorectal adenomatous polyps. Trial registration Clinical Trials.gov, NCT03833492. Retrospectively registered on February 7, 2019.

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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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The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: systematic review and meta-analysis

Endoscopy ◽

10.1055/a-1234-8918 ◽

2020 ◽

Author(s):

De-feng Li ◽

Ming-Guang Lai ◽

Mei-feng Yang ◽

Zhi-yuan Zou ◽

Jing Xu ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Polyps ◽

Complete Resection ◽

R0 Resection ◽

Efficacy And Safety ◽

Resection Rate ◽

En Bloc ◽

Mucosal Resection

Abstract Background Underwater endoscopic mucosal resection (UEMR) is a promising strategy for nonpedunculated colorectal polyp removal. However, the efficacy and safety of the technique for the treatment of ≥ 10-mm colorectal polyps remain unclear. We aimed to comprehensively assess the efficacy and safety of UEMR for polyps sized 10–19 mm and ≥ 20 mm. Methods PubMed, EMBASE, and the Cochrane Library databases were searched for relevant articles from January 2012 to November 2019. Primary outcomes were the rates of adverse events and residual polyps. Secondary outcomes were the complete resection, en bloc resection, and R0 resection rates. Results 18 articles including 1142 polyps from 1093 patients met our inclusion criteria. The overall adverse event and residual polyp rates were slightly lower for UEMR when removing colorectal polyps of 10–19 mm vs. ≥ 20 mm (3.5 % vs. 4.3 % and 1.2 % vs. 2.6 %, respectively). The UEMR-related complete resection rate was slightly higher for colorectal polyps of 10–19 mm vs. ≥ 20 mm (97.9 % vs. 92.0 %). However, the en bloc and R0 resection rates were dramatically higher for UEMR removal of polyps of 10–19 mm vs. ≥ 20 mm (83.4 % vs. 36.1 % and 73.0 % vs. 40.0 %, respectively). In addition, univariate meta-regression revealed that polyp size was an independent predictor for complete resection rate (P = 0.03) and en bloc resection (P = 0.01). Conclusions UEMR was an effective and safe technique for the removal of ≥ 10-mm nonpedunculated colorectal polyps. However, UEMR exhibited low en bloc and R0 resection rates for the treatment of ≥ 20-mm polyps.

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Outcome of a novel modified endoscopic papillectomy for duodenal major papilla adenoma

Surgical Endoscopy ◽

10.1007/s00464-020-07715-0 ◽

2020 ◽

Vol 34 (11) ◽

pp. 5160-5167

Author(s):

Pin Wang ◽

Chengfei Jiang ◽

Yi Wang ◽

Lin Zhou ◽

Shu Zhang ◽

...

Keyword(s):

Endoscopic Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

High Rate ◽

Conventional Group ◽

Incomplete Resection ◽

Resection Rate ◽

En Bloc ◽

Endoscopic Papillectomy ◽

Significant Difference

Abstract Background and aims In recent years, with the development of endoscopic techniques, endoscopic resection is widely used for duodenal papillary adenomas, but conventional endoscopic resection has a high rate of incomplete resection and recurrence. On this basis, we have employed a novel modified endoscopic papillectomy (ESP). In this study, we evaluated the feasibility and advantages of this ESP for the treatment of duodenal major papilla adenoma. Methods A total of 56 patients with duodenal major papilla adenoma confirmed by endoscopic ultrasonography, intraluminal ultrasound and gastroscopic biopsy from October 2007 to June 2017 were collected in the Department of Gastroenterology, Nanjing Drum Tower Hospital. The diameter of the adenoma ranged from 1.41 to 2.02 cm. 16 cases were given the conventional method and 40 cases underwent the modified ESP procedure in which a small incision was made by cutting current when anchoring the snare tip on the distal side of the adenoma. Results En bloc resection rate was significantly higher in the modified group (100%, 40/40) than that in the conventional group (81.3%, 13/16; P = 0.02). However, no significance was seen between the modified group and the conventional group in complete resection rate (92.5%, 37/40 vs 93.8%, 15/16; P = 1.00). There was no significant difference in the number and difficulty of postoperative pancreatic and biliary stents placement between the two groups (P = 0.20). Total bleeding occurrence was much lower in the modified group (37.5%, 15/40 vs 87.5%, 14/16; P = 0.001), and no significant differences were found in other short-term complications and the 3, 6, 12 and 24 months recurrences rate between the conventional and modified ESP groups. Conclusions The modified ESP improves the treatment outcome of duodenal major papilla adenoma with higher en bloc resection rate and lowering bleeding rate.

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Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis

Endoscopy International Open ◽

10.1055/a-1287-9621 ◽

2020 ◽

Vol 08 (12) ◽

pp. E1884-E1894

Author(s):

Rajat Garg ◽

Amandeep Singh ◽

Babu P. Mohan ◽

Gautam Mankaney ◽

Miguel Regueiro ◽

...

Keyword(s):

Systematic Review ◽

Endoscopic Mucosal Resection ◽

Meta Analysis ◽

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Polyps ◽

Incomplete Resection ◽

En Bloc ◽

Delayed Bleeding ◽

Mucosal Resection

Abstract Background and study aims Underwater endoscopic mucosal resection (UEMR) for colorectal polyps has been reported to have good outcomes in recent studies. We conducted a systematic review and meta-analysis comparing the effectiveness and safety of UEMR to conventional EMR (CEMR). Methods A comprehensive search of multiple databases (through May 2020) was performed to identify studies that reported outcome of UEMR and CEMR for colorectal lesions. Outcomes assessed included incomplete resection, rate of recurrence, en bloc resection, adverse events (AEs) for UEMR and CEMR. Results A total of 1,651 patients with 1,704 polyps were included from nine studies. There was a significantly lower rate of incomplete resection (odds ratio [OR]: 0.19 (95 % confidence interval (CI), 0.05–0.78, P = 0.02) and polyp recurrence (OR: 0.41, 95 % CI, 0.24–0.72, P = 0.002) after UEMR. Compared to CEMR, rates overall complications (relative risk [RR]: 0.66 (95 % CI, 0.48–0.90) (P = 0.008), and intra-procedural bleeding (RR: 0.59, 95 % CI, 0.41–0.84, P = 0.004) were significantly lower with UEMR. The recurrence rate was also lower for large non-pedunculated polyps ≥ 10 mm (OR 0.24, 95 % CI, 0.10–0.57, P = 0.001) and ≥ 20 mm (OR 0.14, 95 % CI, 0.02–0.72, P = 0.01). The rates of en bloc resection, delayed bleeding, perforation and post-polypectomy syndrome were similar in both groups (P > 0.05). Conclusions In this systematic review and meta-analysis, we found that UEMR is more effective and safer than CEMR with lower rates of recurrence and AEs. UEMR use should be encouraged over CEMR.

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Comparison of underwater and conventional endoscopic mucosal resection for removing sessile colorectal polyps: a propensity-score matched cohort study

Endoscopy International Open ◽

10.1055/a-1007-1578 ◽

2019 ◽

Vol 07 (11) ◽

pp. E1528-E1536 ◽

Cited By ~ 7

Author(s):

Hsu-Chih Chien ◽

Noriya Uedo ◽

Ping-Hsin Hsieh

Keyword(s):

Cohort Study ◽

Muscle Layer ◽

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Polyps ◽

Matched Pairs ◽

Procedure Time ◽

Resection Rate ◽

En Bloc ◽

Delayed Bleeding

Abstract Background and study aims Endoscopic mucosal resection (EMR) is a standard method for removing sessile colorectal polyps ≥ 10 mm. Recently, underwater EMR (UEMR) has been introduced as a potential alternative. However, the effectiveness and safety of UEMR compared with conventional EMR is un clear. Patients and methods In this 1:1 propensity score (PS) matched retrospective cohort study, we compared the en bloc resection rates, procedure time, intraprocedural and delayed bleeding rates, and incidence of muscle layer injury. We also performed subgroup analyses by sizes of polyps (< 20 mm and ≥ 20 mm). Results Among 350 polyps in 315 patients from August 2012 to November 2017, we identified 121 PS-matched pairs. Mean polyp size was 16.8 mm. With similar en bloc resection rates (EMR: 82.6 % vs. UEMR: 87.6 %, rate difference: 5.0, 95 % confidence interval [95 % CI]: – 4 to 13.9 %), UEMR demonstrated a shorter resection time (10.8 min vs. 8.6 min, difference: – 2.2 min, 95 % CI: – 4.1 to – 0.3 min) and a lower intraprocedural bleeding rate (15.7 % vs. 5.8 %, rate difference: – 9.9 %, 95 % CI: – 17.6 to – 2.2 %). Incidence of delayed bleeding and muscle layer injury were low in both groups. For polyps < 20 mm, effectiveness and safety outcomes were similar in both groups. For polyps ≥ 20 mm (42 PS-matched pairs), the UEMR group has a comparable en bloc resection rate with shorter procedure time and superior safety outcomes Conclusions UEMR achieved an en bloc resection rate comparable to conventional EMR with less intraprocedural bleeding and a shorter procedure time.

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Endoscopic submucosal dissection of large pedunculated polyps with wide stalks: a retrospective multicenter study

Endoscopy ◽

10.1055/a-1194-4413 ◽

2020 ◽

Vol 53 (01) ◽

pp. 77-80

Author(s):

Hideyuki Chiba ◽

Jun Tachikawa ◽

Jun Arimoto ◽

Keiichi Ashikari ◽

Hiroki Kuwabara ◽

...

Keyword(s):

En Bloc Resection ◽

Bloc Resection ◽

Colorectal Polyps ◽

Resection Rate ◽

En Bloc ◽

The Mean ◽

Large Pedunculated Polyps ◽

Submucosal Fibrosis ◽

Retrospective Multicenter Study ◽

Severe Fibrosis

Abstract Background Endoscopic resection of large pedunculated colorectal polyps is technically difficult, especially when the polyp is large and has such a thick stalk that it is either too difficult or impossible to resect prophylactically by a conventional snare. Here, we evaluated the feasibility of ESD for large pedunculated polyps with wide stalks. Methods 29 patients with large pedunculated polyps that were not resectable by polypectomy or endoscopic mucosal resection were enrolled in the study. Results En bloc resection was achieved in 28/29 polyps. One suspended case was due to severe fibrosis with muscle retraction signs. The mean diameter of the 29 polyp heads was 39.7 (standard deviation 6.9) mm. Submucosal fibrosis was present in 16 polyps (9 mild; 7 severe). The stalks of severely fibrotic polyps were significantly thicker than those of polyps with no or mild fibrosis. The curative resection rate was 85.7 % without severe complications. Conclusions ESD is feasible for the removal of large pedunculated polyps with wide stalks when conventional snare resection is difficult or impossible.

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Prevention and Management of Complications and Education in Endoscopic Submucosal Dissection

Journal of Clinical Medicine ◽

10.3390/jcm10112511 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2511

Author(s):

Yoshitsugu Misumi ◽

Kouichi Nonaka

Keyword(s):

Endoscopic Submucosal Dissection ◽

Endoscopic Mucosal Resection ◽

Endoscopic Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

Resection Rate ◽

En Bloc ◽

Educational Methods ◽

Submucosal Dissection ◽

Management Of Complications

Endoscopic submucosal dissection (ESD) is considered superior to endoscopic mucosal resection as an endoscopic resection because of its higher en bloc resection rate, but it is more difficult to perform. As ESD techniques have become more common, and the range of treatment by ESD has expanded, the number of possible complications has also increased, and endoscopists need to manage them. In this report, we will review the management of critical complications, such as hemorrhage, perforation, and stenosis, and we will also discuss educational methods for acquiring and improving ESD skills.

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