Introduction

The evolution of endoscopic techniques allows the treatment of multiple lesions previously reserved for surgical treatment. There are few data of the feasibility of endoscopic submucosal dissection (ESD) for the resection of lesions involving the ileocecal valve and/or invading the terminal ileum. The objective of this study was to assess the efficacy and safety of ESD in this indication.

Aims & Methods

All patients who benefit from an ESD for ileocecal valve lesion were identified from a prospective database. The precise location of the lesion (anal/caecal lip, anterior/posterior commissure, ileal invasion) was collected retrospectively from computer reports and a review of endoscopic films when available. The primary endpoint was the R0 resection rate defined as En Bloc resection with histological free lateral and deep margins.

Results

A total of 116 patients (median age 71 years, 55.2% men) in 3 expert centers were identified. The majority of lesions were granular laterally spreading tumors (LST). The median diameter of the lesions was 45 mm (IQR 36-60) by 35 mm (IQR 27-45). 44.8% (52/116) of the lesions invaded the terminal ileum over 10 mm. The lesion covered less than 50% of the valve in 63.6% of cases, more than 75% in 4% of cases, and the entire valve in 3% of cases.
The median speed of ESD was 25.2 mm2/min (IQR 16.6-46). The en bloc resection rate was 93.9% and the R0 resection rate was 78.4%. Resection was curative in 74.1% of patients (90/116). Factors associated with failed R0 resection were ileal involvement (59.2% vs 85.9% p = 0.041), anal lip involvement (67.8% vs 89.7% p = 0.012) and an involvement of more than 50% of the valve circumference (66.7% vs 84.1% p = 0.011).
Four ESD failed due to muscle ascension (retractile sign) (2/4), a perforation of the ESD resected piece, and a difficult positioning to perform the ESD. Seven patients presented postoperative complications (6.0%) including 6 delayed bleeding and one perforation requiring surgical management.

Conclusion

ESD could be proposed in expert centers as the first option to treat lesions developed on the ileocecal valve. Ileal involvement, anal lip involvement and involvement of more than 50% of the valve appear to be predictive factors for failure.

Introduction

Endoscopic submucosal dissection (ESD) is a highly effective and safe technique for the resection of superficial colorectal neoplasms, but it can still be technically challenging for lesions in contact with or invading the appendiceal orifice. Until recently, appendicular lesions were considered unresectable or difficult to resect by endoscopy because of the high risk of incomplete resection, perforation or acute appendicitis. Small studies have reported ESD feasibility and efficacy in this particular context, including for lesions deeply invading the appendix. However, strong data about these more complex resections is lacking and the best management strategy for this kind of lesion remains a matter of debate, with upfront surgery still being the first-choice treatment in most western countries.

Aims & Methods

With the present study, we aimed to assess and report the outcomes of ESD for the treatment of lesions in contact with or invading the appendiceal orifice. We prospectively collected data of ESD procedures for appendiceal neoplasia in a multicenter prospective register. En Bloc R0 resection rate was the primary outcome. Morbidity and additional surgery were also reported.

Results

A total of 112 patients were included, comprising 47 (42%) with previous appendectomy. Fifty-six lesions (50%) were type 3 according to Toyonaga classification (15 (13.4%) post-appendectomy). En-bloc and R0 resection rates were 86.6% and 80.4%, with no significant difference associated with different grades of appendiceal invasion (p=0.9 and p=0.4, respectively) or history of previous appendectomy (p=0.3 for both). Curative resection rate was 78.6%. Additional surgery was performed in 16 (14.3%) cases, with 10/16 (62.5%) corresponding to Toyonaga type 3 lesions (p=0.04). This included the treatment of 5 (4.5%) cases of delayed perforation and 1 acute appendicitis. A second case of acute appendicitis and 1 of delayed hemorrhage also observed, both treated conservatively.

Conclusion

To our knowledge, this is the largest reported series of ESDs for the treatment of appendicular lesions. Our results show that ESD is safe and effective in this context, and should thus be considered as a valuable treatment option. New traction strategies and devices should make it progressively less technically challenging and more widely accessible.

Introduction

Traction strategies are increasingly becoming the standard approach for endoscopic submucosal dissection (ESD). 'Natural' traction forces, such as gravity, remain valuable during ESD, helping to optimize dissection and improve procedural speed. However, mechanical traction, particularly the adaptive traction strategy, has recently shown promising results in terms of efficacy and safety, including the highest resection speeds reported in the literature for colorectal ESD (1,2).
The aim of our study was to evaluate resection speed based on initial gravitational force in a prospective cohort of patients undergoing colorectal ESD with adaptive traction strategy.

Aims & Methods

Consecutive patients undergoing ESD of conventional colorectal lesions with an adaptive traction strategy at a tertiary referral center between 2023 and 2025 were prospectively enrolled. The initial gravity was classified as favorable/neutral and unfavorable. The primary endpoint was resection speed. A non-inferiority analysis was conducted for the primary endpoint, with the non-inferiority margin set at a 20% reduction in resection speed. Secondary endpoints included the rate of En Bloc resection, the rate of R0 resection and the rate of adverse events.

Results

The study included 118 patients, of whom 78 (66%) had favorable or moderate initial lesion severity and 40 (34%) had unfavorable initial gravity. The mean resection speed in the favorable and moderate gravity group was 37.4 versus 35.8 (p = 0.6067) in the unfavorable group, the R0 resection rate was 86.2% versus 86.8% (p > 0.99), and the perforation rate was 5.9% versus 7.0% (p = 0.7015).
After adjustment for lesion location, operator and lesion area, the resection rate in the unfavorable severity group was very close to the non-inferiority margin (p = 0.07).

Conclusion

In our cohort of patients undergoing colorectal ESD using an adaptive traction strategy, initial gravity did not alter the speed and quality of resection. We can assume that the use of a mechanical adaptive traction strategy allows overcoming the need for the natural traction force provided by gravity, thus avoiding the need to mobilize patients during the procedure to achieve a more favorable gravitational force.

References

(1) Grimaldi J, Masgnaux LJ, Lafeuille P, et al. Endoscopic submucosal dissection with adaptive traction strategy: first prospective multicenter study (with video). Gastrointest Endosc. 2024 Sep;100(3):517-523.
(2) Masgnaux LJ, Grimaldi J, Rivory J, et al. Endoscopic submucosal dissection assisted by adaptive traction: results of the first 54 procedures. Endoscopy. 2024 Mar;56(3):205-211

Disclosure

Jean Grimaldi, Louis-Jean Masgnaux, Romain Legros, Jérome Rivory, Timothée Wallenhorst, Jérémie Jacques and Mathieu Pioche are co-founder of Atract Device & Co.
The other authors have no competing interests related to this study.

Introduction

Endoscopic submucosal dissection (ESD) is widely recognized as the preferred technique for removing large benign colorectal lesions and those with a risk of submucosal invasive cancer (SMIC), with the goal of achieving en-bloc resection. R0 resection is crucial for enabling organ-preservation strategies, particularly in endoscopically resected T1-colorectal cancer (T1-CRC).

Aims & Methods

This study aims to evaluate R0 resection rates in a large cohort of colorectal ESDs by assessing vertical and lateral margins and identifying predictive factors for vertical margin involvement. Furthermore, the presence of other prognostic risk factors for lymph node metastasis (LNM) will be analyzed in this large cohort of T1-CRC. This is a multicenter prospective cohort study in 13 centers, including all colorectal ESDs between 09/2019 and 09/2024. Procedural and histological outcomes were analyzed using univariate and multivariate analysis.

Results

7495 large colorectal polyps were included, of which 781 were T1-CRCs with a median size of 45 [35-65] mm. En bloc resection occurred in 96.7% and R0 resection in 74.9%. Lateral resection margins were free in 92.5%, with positive margins for adenocarcinoma in only 0.8% (low grade dysplasia in 2.6%, high grade in 1.2%, missing data in 2.6%). Vertical margins were free in 80.3%, and decreased significantly when deep SMIC was present to 75.0%, compared to 95.7% for superficial SMIC. However deep SMIC with up to 2000 µm invasion depth, demonstrated free vertical resection margins in still 80.7%, after which it gradually decreased to 73.1% and 67.7% at an infiltration depth of 2000-3000 µm and >3000 µm respectively. Predictive factors for free vertical resection margins include lesion size >50mm (OR=1.66, [1.01;2.71], p=0.045) and rectal location (OR=1.86, [1.04;3.3], p=0.035). Significant difference was observed in the presence of prognostic risk factors for LNM between superficial and deep SMIC, with lympho-vascular invasion (LVI) being present in 9.6% and high-grade tumor budding (Bd) in 17.1% in superficial SMIC, compared to 25.0% and 30.0% respectively, in deep SMIC. However, absence of LVI, Bd or poor differentiation was noted in 75.9% of superficial and 61.7% of deep T1-CRC. Concerning deep SMIC, no relation was observed in the presence of these risk factors with respect to the depth of infiltration.

Conclusion

Following ESD for T1-CRC, the likelihood of achieving free vertical resection margins decreases significantly when invasion depth exceeds 2000 µm. Careful lesion selection through optical diagnosis is therefore critical. To push organ preservation, intermuscular dissection should be considered for T1-CRC with deeper invasion in the rectum. Achieving R0 resection remains paramount, as additional prognostic factors are present in approximately 38% of cases, irrespective of invasion depth.

Introduction

Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different techniques are feasible including endoscopic full thickness resection (EFTR) with the FTRD system and Endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of both techniques for the treatment of those lesions.

Aims & Methods

All consecutive patients with a RCN treated either by FTRD or ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate defined as an En Bloc resection with histological free lateral and deep margins.

Results

A total of 275 patients (median age 70 years, 161 men) who underwent 177 ESD and 98 FTRD for RCN lesions were included among 19 centers. R0 resection was achieved in respectively 83.3% and 77.6% for ESD and FTRD (p=0.245). However, lesions treated by ESD were meanly larger compared with FTRD (p<0.001).The R0 rate in the ESD and FTRD group forlesions from 20 to 30 mm and 30 to 40 mm were respectively 83.9% and 57.1% and 93.6% and 33.3%. In multivariable analysis, ESD procedure was statistically associated with higher en-bloc and R0 resection rates after adjustment on lesion size (p=0.017 and <0.001). The adverse event rate was higher in the ESD group (12.1% vs 6.1%) due mostly to intra operative perforations.

Conclusion

ESD is effective to achieve R0 resection for RCN whatever the size and the localization of the lesions. When residual lesions are smaller than 20 mm, EFTR is an effective alternative.