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RECURRENCE IN LARGE NON-PEDUNCULATED COLONIC LESIONS IS SIGNIFICANTLY HIGHER AFTER COLD SNARE ENDOSCOPIC MUCOSAL RESECTION THAN AFTER THE STANDARD TECHNIQUE. RESULTS OF A RANDOMIZED CONTROLLED TRIAL

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Introduction

Cold snare EMR (CS-SEMR) in large non-pedunculated colonic lesions is an alternative to the standard procedure (C-EMR), with a better theoretical safety profile. Robust scientific evidence on its efficacy is not available.

Aims & Methods

Objectives: Primary: to compare the efficacy between the 2 techniques, measured as the absence of recurrence at 6 months. Secondary: to compare safety profile and technical aspects.
This is a randomized controlled trial (1:1), multicenter, non-blinded, of consecutive non-pedunculated lesions with adenoma or serrated histology, homogeneous type, with size > 20mm.

Results

229 patients, mean age 68 years, male 56.7% (N=130), were randomized to CS-EMR (N=115) or C-EMR (N=114). Overall, 49% were homogeneous granular LST lesions, predominantly adenomas (74.2%); median size 25mm. No differences between groups in baseline or lesion characteristics were found. The recurrence rate at first surveillance colonoscopy (N=215) was significantly higher in the CS-EMR group vs. C-EMR group: 33.6 vs. 16.7% (p=0.007), and 35.1 vs 15.2% (p=0.002) in ITT and PP analysis, respectively. En bloc and R0 resection rates were higher in C-EMR vs. CS-EMR: 23.7% vs. 1.7% p=0.001, and 21.1% vs. 1.7% p=0.001, respectively. There was no difference in the rate of complications: delayed bleeding (CS-EMR 2.6% vs C-EMR 3.5% p=0.722), perforation (0% in both groups) and post-polypectomy syndrome (CS-EMR 0.9% vs C-EMR 1.8% p=0.622). No differences were found in resection time either: CS-EMR 28.23 min vs C-EMR 22.30 min, p=0.297. The median number of fragments was higher in CS-EMR (6) vs. C-EMR (3) p=0.001, while the use of clips was higher in C-EMR (2.21) vs. CS-EMR (1.30) p=0.001.

Conclusion

The recurrence rate is significantly higher after CS-EMR compared to the standard technique. There is a trend towards fewer adverse effects in CS-EMR, without statistical significance in our study.

Disclosure

The authors declare no conflict of interest in relation to this study.

RECURRENCE IN LARGE NON-PEDUNCULATED COLONIC LESIONS IS SIGNIFICANTLY HIGHER AFTER COLD SNARE ENDOSCOPIC MUCOSAL RESECTION THAN AFTER THE STANDARD TECHNIQUE. RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Óscar Nogales 1, Carlos Carbonell Blanco 2, Maria Pellisé Urquiza 3, Juan F. Martínez Sempere 4, Fausto Riu Pons 5, Carolina Mangas-Sanjuan 4, Maria Daca Alvarez 6, Hugo Uchima 7, Javier Aranda Hernández 2, Alberto Álvarez Delgado 8, Eduardo Albéniz-Arbizu 9

1 Hospital General Universitario Gregorio Marañón, Madrid, Spain

2 Hospital General Universitario Gregorio Marañon, Madrid, Spain

3 Hospital Clinic de Barcelona. Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain

4 Hospital Universitario de Alicante Dr. Balmis, Alicante, Spain

5 Hospital del Mar, Barcelona, Spain

6 Hospital Clinic, Barcelona, Spain

7 Hospital Germans Trias i Pujol, Barcelona, Spain

8 Hospital Universitario de Salamanca, Salamanca, Spain

9 Hospital Universitario de Navarra, Pamplona, Spain

Event

UEG Week Copenhagen 2023

Topics

Colorectal

Submission format

Late-Breaking Abstract

Session

Breakthroughs in screening and management of colorectal lesions: Late-breaking abstracts

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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En bloc resection: Can we simplify it?

Jérémie Jacques 1

1 CHU Limoges - Hepato-Gastro-Enterology, CHU Limoges; Limoges/FR, Limoges, France

Event

UEG Week Copenhagen 2023

Topics

Endoscopy Surgery

Session

Crash course: Endoscopic resections

Published

2023

UEG Presentation

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TOPFLIGHT ESD: A NOVEL STRATEGY FOR THE RESECTION GASTRIC FUNDUS TUMORS

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Introduction

Gastric fundus is a technically difficult area for endoscopic submucosal dissection(ESD), even for experienced endoscopists, due to its anatomic features, thin wall, and abundant blood supply.

Aims & Methods

To evaluate the feasibility a novel ESD technique, the “topflight ESD” for the gastric fundus tumors resection.
Topflight ESD procedure: marking dots are applied 5 mm outside the lesion margins, using the tip of the ESD knife; a mucosal incision is made in the distal esophagus, ca 3 cm above gastroesophageal junction; a tunnel is created into the gastric wall; subepithelial injection is performed using an endoscopic needle and the water flush from the ESD knife; extensive dissection of the submucosal space in the fundus and proximal corpus is performed; the tumor is isolated from the surrounding tissues; the endoscope is removed from the submucosal tunnel and is inserted into the gastric lumen; mucosal incision is performed outside the dots rim using the ESD knife; en bloc resection is obtained, the specimen is retrieved; finally, the esophageal incision is closed using conventional through-the-scope clips.

Results

An 81-year-old male patient with history of a coronary bypass surgery, right lung lobectomy and MALT lymphoma, was referred to us. On a previous gastroscopy, a 6 cm flat lesion with no ulcer(Paris 0-IIa+b), was identified in the gastric fundus and greater curvature of the proximal body. Biopsies revealed a mixed type, moderately differentiated adenocarcinoma. After multidisciplinary team conference a decision for ESD resection was made. The ESD was performed according to the steps described above. After lesion characterization, marks were placed around the lesion. Then, an incision was made in the distal esophagus and a wide tunnel was created, dissecting the submucosa under the lesion. Then, a mucosal incision from the luminal side was made. During this stage there was a 3mm perforation, highlighting the risk of perforation when the cutting is done from the luminal side. That perforation was effectively closed with the use of through-the-scope clips. En bloc resection was achieved. The esophageal incision was closed. The obtained specimen was 75x50mm in size. Oral liquids were started on day 1 and the patient was discharged asymptomatic, on day 2. The pathological examination confirmed the presence of a mixed type, moderately differentiated adenocarcinoma SM2L0V0R0, pT1b. The patient was under clopidogrel and was admitted at day 10 due to bleeding from the ESD ulcer, treated endoscopically, and remains asymptomatic 2 months after.

Conclusion

We demonstrate a novel and minimally invasive endoscopic option that uses conventional ESD devices. To our best knowledge, this is the first report of gastric fundus epithelial tumor resection using this technique. The Topflight ESD might be considered in such cases in the future.

References

1. Hamada K, Horikawa Y, Koyanagi R, Shiwa Y, Techigawara K, Nishida S, Nakayama Y, Honda M. Usefulness of a multibending endoscope in gastric endoscopic submucosal dissection. VideoGIE. 2019 Oct 19;4(12):577-583.
2. Kitamura M, Miura Y, Shinozaki S, Yamamoto H. The pocket-creation method facilitates gastric endoscopic submucosal dissection and overcomes challenging situations. VideoGIE. 2021 May 28;6(9):390-394.
3. Baldaque-Silva F, Vilas-Boas F, Velosa M, Macedo G. Endoscopic submucosal dissection of gastric lesions using the "yo-yo technique". Endoscopy. 2013;45(3):218-21.
4. Baldaque-Silva F, Wang N, Rouvelas I, Omae M. Traction-assisted endoscopic submucosal dissection of a duodenal gastrointestinal stromal tumor. Endoscopy. 2022 Jun;54(6):E318-E319.
5. Omae M, Wang N, Löhr JM, Vujasinovic M, Baldaque-Silva F. Endoscopic submucosal dissection by using a new traction device. VideoGIE. 2021 Oct 27;6(12):543-545.
6.Baldaque-Silva F, Wang N, Omae M. Duodenal subepithelial neuroendocrine tumor removed by endoscopic submucosal dissection using internal traction with magnets. VideoGIE. 2022 Apr 23;7(7):259-261.

TOPFLIGHT ESD: A NOVEL STRATEGY FOR THE RESECTION GASTRIC FUNDUS TUMORS

João Pereira 1, Henrik Maltzman 2, Miroslav Vujasinovic 2, Naining Wang 3, Masami Omae 2, Francisco Baldaque-Silva 4

1 Advanced Endoscopy Center Carlos Moreira da Silva, Gastroenterology Department, Pedro Hispano Hospital, Matosinhos, Portugal

2 Center for Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden, Stockholm, Sweden

3 Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden, Stockholm, Sweden

4 Advanced Endoscopy Center Carlos Moreira da Silva, Gastroenterology Department, Pedro Hispano Hospital, Matosinhos, Portugal|||Center for Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden, Stockholm, Sweden