Introduction

Although endoscopic submucosal dissection (ESD) can be useful for treating early colorectal neoplasms, colorectal ESD is technically more difficult, with certain organ characteristics rendering the procedure even more challenging and increasing the risk of perforation. Herein, we used scissor-type knives (SB Knife Jr and Jr2, Sumitomo Bakelite, Japan) that enabled the maintenance of an adequate dissection layer and prevented unexpected muscular layer injuries. However, scissor-type knives demonstrated slower resection compared with needle-type knives. This drawback was overcome by using a traction device on the lesion, which facilitated accurate visualization and easier dissection as well as increased the resection speed during colorectal ESD using a needle-type knife. Nevertheless, reports regarding the effectiveness of a traction device when using a scissor-type knife for colorectal ESD remain scarce.

Aims & Methods

This study aimed to evaluate the efficacy and safety of ESD performed using a scissor-type knife with and without a traction device for treating early colorectal neoplasms. Between October 2010 and January 2023, ESD was performed for 619 lesions in 582 patients (male-to-female ratio, 332:250; mean age, 70.0 years) in the Kure medical center. ESD was performed without a traction device for 531 lesions (Group A) and with a traction device for 88 lesions (Group B). We compared the en-bloc resection rate, complete resection rate, tumor size, procedure time, resection speed, and adverse events of the groups.

Results

Five and two interruptions occurred in Groups A and B, respectively. The en-bloc resection rate was 99.0% (521/526) in Group A and 97.7% (84/86) in Group B (p = 0.26). The complete resection rate was 97.0% (510/526) and 95.3% (82/86) in Groups A and B, respectively (p = 0.51). The mean tumor diameter was 33.4 ± 16.9 and 37.2 ± 20.9 mm in Groups A and B, respectively (p = 0.11). The mean procedure time was 86.4 ± 67.6 and 73.2 ± 66.0 min in Groups A and B, respectively (p = 0.09). The mean resection speed (the resected specimen area [mm²] divided by the procedure time [min]) was 13.2 ± 10.4 and 22.9 ± 11.9 mm²/min in Groups A and B, respectively, with the speed in Group B significantly faster than that in Group A (p < 0.01). There was one case each of intraoperative perforation and delayed perforation in Group A (1/526, 0.2% each), while there were none in Group B (0/86, 0%). Both cases of perforation were treated conservatively. There were 10 cases of delayed hemorrhage in Group A (10/526, 1.9%), and none in Group B (0/86, 0%; p = 0.37). The hemorrhage was controlled with endoscopic hemostasis in all cases.

Conclusion

ESD using a scissor-type knife either with or without a traction device is technically efficient and safe. Moreover, its drawback of slow resection speed may be overcome by the use of a traction device.

Introduction

Endoscopic colonic stenting is a treatment method in which a colonoscope is used to insert a self-expandable metal stent (SEMS) into a stenotic site and allow its expansion to alleviate colonic obstruction and permit urgent colonic decompression. It is an effective and extensively practiced minimally invasive procedure compared with emergency surgery. However, perforation, stent migration, and reocclusion may occur. Perforation is particularly a serious adverse event with a mortality rate of 50%. There are three possible causes of perforation:
(1) Local perforation due to stimulation of the stent itself directly into the intestinal tract;
(2) Perforation due to guidewire or catheter manipulation during stent insertion; and
(3) Perforation due to increased pressure in the intestinal tract at the oral side of the obstruction (especially in the cecum) caused by air supply during colonoscopy insertion.
For the first possible cause, an improved colonic stent was developed to reduce irritation to the intestinal tract, and for the second possible cause, a strategy for safe stent insertion was established.
However, perforation due to the third possible cause remains a concern, and appropriate countermeasures should be urgently developed.
In endoscopic colonic stenting, we hypothesized that colonoscope insertion using the gel immersion method, which uses a recently developed endoscopic view-securing gel, would allow safe and rapid access to the lesion without increasing intestinal pressure, thereby decreasing the incidence of perforation.

Aims & Methods

This study aimed to clarify the usefulness of the gel immersion method during colonoscope insertion with endoscopic view-securing gel for colonic stenting. Eight patients in whom colorectal stenting was performed using the gel immersion method between May 2022 and January 2023 were included.
The primary endpoint was the endoscopic lesion reach rate, and the secondary endpoints were the technical and clinical success rates of SEMS deployment, colonoscope insertion time, total procedure time, and adverse event rate.

Results

Of the included patients, four were males (50%), and the mean age of patients was 67.6 ± 15.6 years. Seven patients (87.5%) had colorectal cancer and one patient (12.5%) had gastric cancer. The cancer was localized at the following sites: sigmoid colon in three patients, descending colon in three patients, transverse colon in one patient, and ascending colon in one patient. The purpose of SEMS deployment was bridge to surgery in four (50%) and palliation in four (50%) patients. In all cases, the endoscope was inserted without the preparation and insertion of the endoscope into the lesion at the origin of the obstruction without insufflation, and the endoscopic lesion reach rate was 100% (8/8). No worsening of intestinal dilatation was observed. The technical and clinical success rates each were 100% (8/8). The scope insertion time was 9.8 ± 5.2 min, total procedure time was 27.3 ± 6.5 min, and the adverse event rate was 0% (0/8).

Conclusion

For endoscopic colonic stenting, endoscope insertion using the gel immersion method could be performed safely and effectively and has the potential to become the standard method.

Introduction

Colorectal endoscopic submucosal dissection (C-ESD) has been established as a standard treatment for colorectal neoplasms which need to be resected in an en bloc fashion. However, the dissection of thin submucosa under inadequate visualization is still technically demanding. A traction device is a key to this problem.

Aims & Methods

We recently developed a novel traction device (multi-loop traction device, MLTD; Boston Scientific Co. Ltd., Tokyo, Japan). The present study focuses on evaluating the effectiveness and safety of MLTD during C-ESD. A multicenter randomized controlled trial was conducted involving patients aged 20 years or older with colorectal lesions (≥ 20 mm) suspected of non-invasive carcinoma. Participants were randomly assigned in 1:1 ratio to undergo ESD with MLTD (MLTD-ESD group) or without any traction device (control group). In both groups, the operators were given the option to convert the treatment to the other group if endoscopist found it difficult to continue treatment under the conditions given in each group for more than 10 minutes. The primary endpoint was dissection speed, with key secondary endpoints being technical success rate and adverse events. The technical success rate was defined as the proportion of cases in which the protocol treatment was completed in each group.

Results

A total of 108 participants were randomized into the MLTD-ESD group (n = 53) and the control group (n = 55). Median dissection speeds were not significantly different between the MLTD-ESD group and the control group (14.8 [IQR: 8.9-23.9] vs. 13.3 [IQR: 8.9-18.8] mm²/min; P = 0.30). However, the technical success rate was significantly higher in the MLTD-ESD group (96.2%) compared to the control group (71.0%). There were two cases in which treatment was converted in the MLTD-ESD group, and 16 cases in which treatment was converted in the control group. There was no significant difference between the MLTD-ESD group and the control group in the en bloc resection rate (98.1% vs. 100%, P = 0.31), R0 resection rate (94.3% vs. 91.0%, P = 0.46) and the incidence of adverse events (7.5% vs. 9.1%, P = 0.77). Two intraoperative perforations, one delayed bleeding, and one delayed perforation occurred in the MLTD-ESD group. All patients recovered with nonsurgical management. The subgroup analysis among expert endoscopists with over 200 clinical ESD experiences showed a faster dissection speed in the MLTD-ESD group compared to the control group (21.6 [IQR: 15.5-28.8] vs. 14.4 [IQR: 9.9-21.2] mm²/min; P = 0.009).

Conclusion

The use of MLTD did not lead to a faster dissection speed during C-ESD in this multicenter randomized controlled trial. However, it was associated with a higher technical success rate, and faster ESD procedures among expert endoscopists. To better define its role in C-ESD, further research with a more targeted approach is warranted.

Disclosure

Kazuki Sumiyama is named as an inventor in patent licensing of the “Multi-Loop Traction Device.”

Introduction

A positive resection margin after endoscopic submucosal dissection (ESD) of a colorectal neoplasm is associated with an increased risk of recurrence. However, it may be caused by cauterization or tangential specimen cutting. We aimed to identify the clinical significance of positive resection margins in colorectal neoplasms after ESD.

Aims & Methods

We reviewed 1010 patients who underwent colorectal ESD at two hospitals between 2015 and 2020. The inclusion criteria were that the patient 1) had an en bloc resection, 2) had at least one follow-up colonoscopy. The recurrence rates and presence of residual tumors in the surgical specimens were evaluated.

Results

A total of 632 patients were enrolled. Among them, 557 patients had complete resections, and 75 had incomplete resections with positive resection margins in vertical and/or horizontal margin. The rate of additional surgery after ESD and recurrence was significantly higher in patients with incomplete resection compared to patients with complete resection. However, in patients with non-invasive colorectal neoplasm, all 411 patients, including those with complete and incomplete resection, had no recurrence. Among 221 patients with invasive lesions, 39 underwent additional surgery due to non-curative resection. Positive vertical margin and lymphovascular invasion were associated with remnant tumors in the surgical specimen. Lymphovascular invasion was associated with lymph node metastasis. However, no remnant tumor nor lymph node metastases were found in patients with only one unfavorable histological factor, including 1) positive vertical margin, 2) a submucosal invasion depth > 1000 µm, 3) lymphovascular invasion, 4) poorly differentiated cancer, and 5) high tumor-budding grade.

Conclusion

A positive resection margin after en bloc colorectal ESD for noninvasive lesions was not associated with recurrence. In T1 colorectal cancer with a positive vertical resection margin, salvage surgery can be considered in selected patients with additional risk factors.

Introduction

During endoscopic submucosal dissection (ESD) of colorectal neoplasms, an interesting feature is occasionally detected in which the muscle layer under the tumour seems to be pulled upwards into the lesion in a triangle-shape. This feature is named muscle retracting sign (MR sign) and appears to indicate a potentially difficult ESD with high risk of incomplete and non-curative resection, although data about this subject is still scarce, without current studies in western countries. The aim of this study was to evaluate whether or not MR sign is associated with worst outcomes.

Aims & Methods

A retrospective analysis, using a prospectively collected database from 2 western centres, including all patients who underwent ESD for colorectal neoplasms with positivity for MR sign from July 2017 to January 2023 was performed. The presence of MR sign was determined by the endoscopist during the procedure. The results were evaluated in terms of complete, en bloc, R0 and curative resection rates, complications and local recurrence.

Results

In a total of 411 lesions treated by ESD, 26 presented MR sign (6.3%, mean size 62,3mm, range 20-180mm): 9 colonic and 17 rectal, corresponding to 26 patients (male 61.5%, mean age 70 years): 9 in colon and 17 in rectum. Morphologically and according to Paris classification, 13 were 0-Is (50%), 10 LST-G-M (38.5%), 1 0-Isp, 1 LST-G-N and 1 LST-NG-F. Technical success was achieved in 24 lesions (24/26, 92.3%) with 2 procedures aborted due to the perception of high perforation risk, both located in the colon (2/9, 22%). In the rectum, there was the need to perform intramuscular dissection in 3 procedures to complete the resection (3/17, 17.6%). Among resected lesions, en bloc and R0 resection rates were 100% and 66.7% (16/24). According to ESGE 2022 criteria, resection was considered curative in 66.7% (16/24), non-curative with high risk in 8.3% (2/24) and with local-risk recurrence in 25% (6/24). Intraprocedure complications were recorded in 2 resections (8%), both in the rectum and both perforations endoscopically managed. No recurrence was recorded in a mean follow-up time of 7 months (range 1-22 months).

Conclusion

This analysis show that MR sign is mostly present in large bulky protruding lesions and seems associated with a higher incomplete resection procedure rate in colon lesions but in rectum. Also, it seems associated with higher complication rate, namely perforations, and non-curative resection rates among resected lesions. Therefore, in the colon, an anticipated switch for surgery in clinically fit patients should be considered in the presence of this sign or even before initiating ESD when lesion morphology suggests its presence. To the authors’ best knowledge, this is the first study of the impact of the present of MRS in ESD in the West.

References

Toyonaga T, Tanaka S, Man-I M, East J, Ono W, Nishino E, et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open. 2015;3(03):E246–51.
Suzuki N, Dhillon A, Seward E, Humphries A. CLIP MUSCLE PROTECTION (CLIMP) METHOD IN MUSCLE-RETRACTING SIGN DURING COLONIC ENDOSCOPIC SUBMUCOSAL DISSECTION. Gut. 2021;70(Suppl 1):A1–A262.

Disclosure

Toyonaga T, Tanaka S, Man-I M, East J, Ono W, Nishino E, et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open. 2015;3(03):E246–51.

Introduction

Piecemeal endoscopic mucosal resection (EMR) vs endoscopic submucosal dissection (ESD) has been a long standing debate in the endoscopic community worldwide with multiple studies done to evaluate the preferred method to manage large colorectal neoplasms. Piecemeal EMR with thermal ablation of the margin has been strongly advocated and reported by certain groups to be a simple, inexpensive and effective technique and this has been preferred widely due to its perceived ease of performance and shorter learning curve.¹ However, close, repeated surveillance colonoscopy is recommended even when the lesion is thought to have been completely resected² as residual tumors can cause interval cancers.³ Some groups, mainly from east Asian countries, have recommended en bloc resection by ESD due to significantly lower risk of local recurrence and precise pathological diagnosis.⁴ But its usage is limited due to concerns about risk of serious adverse events. With improvement in training and devices, colorectal ESD is now being performed by various centers globally. This study aims to report the outcomes of an international, multicenter study on colorectal ESD.

Aims & Methods

Patients who underwent colorectal ESD for lesions greater than 20mm between January 2022 to April 2024 from centers in USA, Japan, and India respectively were included in this study. Recurrent lesions after endoscopic therapy, neoplasms identified in patients with ulcerative colitis, and non-epithelial lesions were included. Primary outcomes were en bloc and R0 resection rate, delayed adverse events (bleeding/perforation), and local recurrence rate. Secondary outcomes were procedure time, lesion size, and pathology. Univariate and multivariate analysis were done to identify the risk factors for primary outcomes.

Results

309 patients (median size, 40(27.5-60)mm; location rectum 52.4%, left colon 26.2%, right colon 21.4%) were involved in this study. The en bloc resection rate was 96.1% and R0 resection rate was 90.3%. 3 patients experienced delayed bleeding which was managed endoscopically. 2 patients underwent surgery for delayed perforation. 6 patients had a local recurrence. 67(23%) patients had intramucosal carcinoma on pathology. Univariate analysis showed lesser procedure time (median(IQR) 145(80-236.25) vs 270(180-300) minutes, P= 0.005) and smaller lesion size (median(IQR) 40(26-56.25) vs 60(40-90) mm, P= 0.004) were significant factors for successful en bloc resection. However, lesser procedure time (median(IQR) 74(29.5-97.5) vs 150(82.5-240) minutes, P= 0.034) led to an increased delayed adverse event rate. Multivariate analysis using Cox regression showed en bloc resection (odds ratio 0.038; 95% confidence interval 0.003-0.421; P= 0.008) was an independent factor preventing local recurrence.

Conclusion

This international, multicenter study with data from three countries shows favorable outcomes for colorectal ESD for large lesions. The high en bloc and R0 resection rate, and low adverse event rate show increased global adaptation to this procedure. Reduced local recurrence is an added benefit. Data from a more centers globally will be valuable to establish ESD as the standard for large colorectal neoplasms.

References

1. Sidhu M, Shahidi N, Gupta S et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology. 2021 Jul 1;161(1):163-70.
2. Gupta S, Lieberman D, Anderson JC et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:463-485.e5.
3. Rutter MD, Beintaris I, Valori R et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018;155:909-925.e3.
4. Ohata K, Kobayashi N, Sakai E et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology. 2022 Nov 1;163(5):1423-34.