Introduction

Endoscopic treatment of the colorectal lesions involving the diverticulum is difficult, due to the lack of muscular layer. There have been no investigations of the safety and feasibility of treatment strategy for the polyp close to or extending into the diverticulum. We investigated the outcomes of our treatment strategy for involving the diverticulum and verify the safety and the feasibility of our strategy.

Aims & Methods

Between November 2014 and January 2022, 33 cases of 33 diverticular polyp (16 males/17 females, age were 74 (54-92) years old) were enrolled in this study. Our treatment strategy for the colorectal lesions involving the diverticulum is determined by the location of polyps and diverticulum, the size of polyp, and the potential of malignancy. Cold polypectomy (CP) and gel-immersion EMR (GIEMR) are selected for the benign polyp of 10 mm or less that can be snared. The polyp with large diverticular openings, we try to inverted diverticulum.When snaring is difficult, ESD is performed. The lesions close to the diverticular opening could be resected by first incising and trimming the area close to the diverticular opening. When lesions extending into the diverticulum, ESD with the ring thread traction is performed. If traction alone cannot complete the procedure, ESD with a minor incision in the muscular layer is used in combination with traction.

Results

3 cases of CSP, 8 cases of GI EMR, and 22 cases of ESD were performed. All cases in which CSP was performed were flat type, two polyps were located in the ascending colon and one in the sigmoid colon, the median size of polyps is 3 (3-5) mm, and all polyps were adenomas. The median time of treatment was 3 (2-5) minutes, en-bloc resection was achieved in all cases, and resected margins were all negative. GI EMR: Endoscopic classification were flat type lesions in 5 cases and elevated type lesions in 3, Four polyps were located in the ascending colon and one each in the cecum, transverse colon, descending colon, sigmoid colon, the median size of lesions is 10 (8-15) mm, the pathological findings were adenomas in 5 cases and SSLs in 3 cases. The median time of treatment was 5 (2-10) minutes, en bloc resection in all cases, and margins were negative. ESD: Of the 22 cases, 17 lesions located near the diverticular opening, and 5 lesions extended completely into the diverticulum. The lesions that extended into the diverticulum, 1 case was resected by diverticulum inversion, 3 cases by ring thread traction, and 1 case by traction with a minor incision in the muscular layer. Endoscopic classification were flat type lesions in 11, elevated type lesions in 11, 5 lesions were located in the cecum, 10 lesions in the ascending colon, one lesion in transverse colon, 6 lesions in sigmoid colon, the median size of lesions is 25 (10-108) mm, the pathological findings were adenomas in 5 cases and intramucosal carcinoma in 17 cases. The median time of treatment was 35 (14-120) minutes, the median diameter of resection was 35 (20-110) mm, no complications were observed, and the horizontal margins were negative.

Conclusion

Endoscopic treatment can be performed safely by selecting a treatment method/strategy suitable for the characteristics of the colorectal lesions involving the diverticulum.

Introduction

ESD of the colorectal lesions involving the appendiceal orifice (AO) is technically challenging because of the thin wall and narrow working space. On the other hand, even if the lesions are small and benign, it is difficult to perform EMR because of the narrow snaring space. We previously reported strip biopsy (SB) resection of the AO lesion. The SB technique is as follows (1) Insert a 2-channel scope and check the lesion. (2) Insert a snare and grasping forceps into each channel, and hold the grasping forceps in the snare. (3) Grasp the appendiceal end of the lesion with the grasping forceps, open the snare, grasp the lesion, and resect it. This method makes it possible to snare the lesion after confirming the distal border of the AO. In the present study, we evaluated the feasibility of SB for AO lesions.

Aims & Methods

This was a retrospective study in which SB for AO lesions was performed on 10 patients at our hospital. Inclusion criteria for the study cohort were (1) the lesion less than 15 mm, and (2) visible lesion margin on the appendicular side. Polyps suspected to be cancerous were excluded.

Results

Male to female ratio was 8:2, median age (range) was 76 years (44-89). The median tumor size was 10 mm (10-15). The pathological findings were 8 cases of SSL and 2 cases of low-grade tubular adenoma. All lesions were resected en bloc, with a median treatment time of 10 minutes (range (5-10)). No complications were observed. Pathology results were negative for 8 cases and unknown for 2 cases. All lesions were resected endoscopically with no residuals.

Conclusion

SB technique for AO lesions is safe and it appeared that this could be one option for endoscopic treatment of AO lesions.^​

Introduction

The degree of fibrosis during colorectal ESD varies and sometimes makes the procedure itself difficult. Preoperative prediction of fibrosis is expected to help develop a reliable strategy.

Aims & Methods

Of 1309 colorectal ESD lesions performed at our hospital between April 2012 and September 2022, 953 lesions larger than 20 mm were included after excluding post-treatment recurrence, SMT, and other conditions. Intraoperative fibrosis was classified into F0 (none), F1 (mild), and F2 (severe).

Results

Fibrosis was observed in 192 (20.1%) patients (F1; 143, F2; 49). The tumor diameter (median, range) was 23 (20-135), 30 (20-210), and 35 (20-115) mm in F0, F1, and F2 groups, respectively. The rate of the cecum (%) was 13.3 : 29.4 : 16.3, which was higher in F1. Overall, bleeding was observed in 17 patients (1.8%) and perforation in 3 patients (0.3%), and the frequency was similar in each group. The curative resection rate (%) was 98.4:91.6:59.2, with F2 being significantly inferior. The long treatment time (≥120 minutes) (%) was 1.7 : 9.1 : 46.9, showing a significant difference between F0 vs F1 and F1 vs F2, and the dissection speed (mean±SD, mm²/min) was 25.9±14.5 : 23.2±13.6 : 15.3±10.6, which was significantly slower in F2. The predictive factors of F1 and F2: straddling the folds, prior biopsy, lesion diameter, site, and morphology, were included in the study, and multivariate analysis showed that the predictive factors of F1 were straddling folds (OR;2.07,95%CI;1.39-3.11), lesion diameter ≥50mm (OR;4.68,95%CI;2.45-8.94), biopsy (OR;6.44,95%CI;3.32-12.5), NGPD (OR;4.31,95%CI;2.37-7.83), and cecum(OR;3.73,95%CI;2.35-5.92). The predictive factors of F2 were straddling folds (OR;2.34,95%CI;1.21-4.51), lesion diameter ≥50 mm (OR;7.29,95%CI;3.03-17.5), biopsy (OR;5.07,95%CI;1.81-14.1), and protruded type (OR;6.44,95%CI;3.23-12.8).

Conclusion

Colorectal ESD for fibrotic lesions was safe, but the curative resection rate was low in F2. F1-specific predictors were cecum and NGPD, and F2-specific predictors were protruded type, suggesting that the choice of surgeon and strategy should depend on the expected degree of fibrosis.

Introduction

Piecemeal endoscopic mucosal resection (pEMR) is a widely used technique for the removal of colonic lesions. Despite its effectiveness, recurrence remains a significant concern in clinical practice. Identifying factors associated with recurrence is essential for improving patient outcomes and guiding post-procedure treatment strategies. The Sydney EMR Recurrence Tool (SERT) provides a standardized method for assessing recurrence risk and identifying key factors contributing to recurrence (1).

Aims & Methods

This study aimed to evaluate the factors associated with recurrence in patients with colonic lesions ≥20 mm treated with piecemeal endoscopic mucosal resection (pEMR) and who had endoscopic follow-up. Specifically, we aimed to identify the prognostic factors using Kaplan-Meier survival analysis, log-rank tests, and multivariate Cox regression. We retrospectively analyzed data from 63 patients who underwent pEMR for colonic lesions ≥20 mm between 2021 and 2024 at a single tertiary center in Italy. The Kaplan-Meier method was used to evaluate time to recurrence based on the presence of high-grade dysplasia (HGD), right colon lesions, granular laterally spreading tumor (LST) type, and lesion size. Log-rank tests were employed to compare survival distributions between these groups. Multivariate Cox regression was used to identify independent predictors of recurrence. A p-value <0.05 was considered statistically significant.

Results

The mean age of the 63 patients was 67.6 ± 9.9 years, and the mean lesion size was 30.4 mm ± 10.6. After a mean follow-up of 7 months, the overall recurrence rate was 23.8% (15/63 patients). In univariate analysis, HGD and lesion size were the only variables associated with a higher risk of recurrence. After multivariable adjustment, only HGD was independently associated with a higher risk of recurrence (HR 5.73, 95% CI, 1.16–28.28; p = 0.03).

Conclusion

Our study highlights that high-grade dysplasia (HGD) is a significant predictor of recurrence in colonic lesions treated with pEMR, while lesion size and location did not show a significant correlation with recurrence. These findings emphasize the importance of close follow-up for patients with a diagnosis of HGD and suggest that the use of targeted surveillance strategies may improve patient outcomes after pEMR.

References

1) Tate DJ, Desomer L, Klein A, Brown G, Hourigan LF, Lee EY, Moss A, Ormonde D, Raftopoulos S, Singh R, Williams SJ, Zanati S, Byth K, Bourke MJ. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc. 2017 Mar;85(3):647-656.e6.

Introduction

CSDP (Cold Snare Defect Polypectomy) after CSP (Cold Snare Polypectomy) for colorectal lesions has been reported to be a factor related to pathological incomplete resection because it causes incomplete mucosal resection and specimen fragmentation. When CSP is performed, it is difficult to resect only with snaring, so it may be necessary for the endoscopist to pull the snare sometimes. However, There is no previous reports about CSP with this technique, and no study has examined “Forced” CSP (FCSP). We have the impression that CSDP is often recognized empirically in FCSP, and we investigated the frequency, safety, and validity of FCSP.

Aims & Methods

A prospective observational study was conducted with the primary endpoint being the frequency of FCSP among the CSPs performed at our hospital from November 2020 to June 2021. The patients were classified into the FCSP group and the conventional CSP group (CCSP). The rate of perforation was evaluated for safety, and the incidence of CSDP and the rate of unclear pathological margins were evaluated for validity.

Results

CSP was performed in 1391 lesions, and Forced CSP was performed in 110 lesions (7.9%). There were no cases of perforation, but CSDP was significantly higher in the Forced CSP group (96.4% (106/110) vs 6% (77/1281), p<0.001), and cases with unclear pathological margins were also used. It was significantly higher in the Forced CSP group (12.7% (14/110) vs 5.7% (75/1279), p=0.0126). In an investigation of predictors for the need for Forced CSP, cecal polyps (OR, 2.6; 95% CI=1.483-4.55; p<0.001) and polyps ≥6 mm (OR, 11.36; 95% CI=7.277 -17.727; p<0.001) was identified as an independent related factor in the multivariate analysis.

Conclusion

FCSP does not affect the complication rate, but the incidence of CSDP and the rate of unclear pathological margins are significantly high. Further investigation at multiple institutions is desired in the future.

Introduction

Colorectal endoscopic submucosal dissection (ESD) is not widely performed in western countries due to technical complexity, risk of adverse events, and procedure time. Hybrid ESD (H-ESD) - partial submucosal dissection followed by snare-assisted resection – may be useful to achieved endoscopic resection in difficult situations. In our center we use H-ESD as rescue therapy during conventional ESD in case of unstable position, inability to achieving appropriate and safe knife angle, advanced submucosal fibrosis or thin submucosal layer and patient instability.

Aims & Methods

We retrospectively analyzed colorectal ESD performed in our centre between January 2014 and March 2023, colorectal lesions in inflammatory bowel diseases were excluded. Univariate and multivariate analyses were conducted to examine factors that may have influenced switch to H-ESD.

Results

A total of 281 colorectal ESDs for superficial neoplasms in 276 patients were considered. 160 patients (58%) were male with an average age of 68,9 years. In 55 (19,6%) cases ESD was switch to H-ESD.. 171 lesions were located in the colon (60.8 %) and 110 (39.1%) in the rectum; mean maximum diameter of the neoplasms was 35,9 mm (SD 18,4 mm). En bloc resection and complete resection (en bloc resection and R0) were achieved in 259 (92 %) and 245 (86 %) cases respectively.
On univariate analysis, the use of waterjet system-assisted knife (OR 0,3; 95% CI 0,17-0,57), underwater-ESD (OR 0,24; 95% CI 0,09-0,63), rectal localization (OR 0,17; 95% CI 0,07-0,40) and granular laterally spreading morphology (OR 0,40; 95% CI 0,21-0,75) were significantly associated to the achievement of complete ESD. Proximal colon localization (OR 3,9; 95% CI 2,08-7,30), severe submucosal fibrosis (OR 4,9; 95% CI 2,51-9,63), non-granular laterally spreading morphology (OR 2,31; 95% CI 1,27-4,21) and maximum diameter < 40 mm (OR 3,91; 95% CI 1,83-8,38) were related to the switch to H-ESD. On multivariate analysis only waterjet system-assisted knife use and U-ESD were significantly correlated with achievement of complete ESD; severe submucosal fibrosis and proximal colon localization resulted significantly related to the switch to H-ESD.

Conclusion

The use of waterjet system-assisted knife and underwater technique reduce the need to switch to H-ESD during endoscopic submucosal dissection of superficial colorectal lesions. Severe submucosal fibrosis and proximal location are risk factors for the need for the H-ESD switch.