Introduction

Clinically significant delayed bleeding (CSDB) is the most frequent complication after colorectal endoscopic submucosal dissection (ESD). The Limoges Bleeding Score was recently developed to identify patients at risk of CSDB after colorectal ESD. The efficacy of prophylactic clipping to prevent bleeding has been a topic of ongoing debate.

Aims & Methods

This study aimed to evaluate the real effectiveness of complete clip closure in preventing CSDB after colorectal ESD.
We performed a retrospective analysis of data prospectively collected from ten-centers between 2017 and 2023. Specifically, pre- and periprocedural data were collected prospectively, while post-procedural data, including the evaluation of CSDB, was retrospectively assessed. All epithelial colorectal lesions treated by ESD were included. The patients were allocated into the closure and non-closure groups which were compared before and after propensity-score matching based on risk factors of the Limoges Bleeding Score (age > 75 yrs, size > 50 mm, ASA III-IV, location in rectum and anticoagulant/antiplatelet). We further analyzed post-ESD CSDB in the subgroups of patients on anticoagulants and with high risk of bleeding (5 to 8 points according to Limoges score).

Results

A total of 3431 patients were included, 1236 in the closure group and 1985 in non-closure group. The propensity score matching based on risk factors of the Limoges Bleeding Score created 1064 matches pairs. The rate of CSDB was not significantly different between the two groups (closure group 7.04% vs non-closure group 6.8%; p = 0.85), nor after propensity score matching (closure group 7.47% vs non-closure group 6.11%; p = 0.38). The subgroup analysis including patients on anticoagulants (165 patients in closure group vs 251 in non-closure group) and those identified at high-risk by Limoges score (181 in each group), found no significant difference of CSDB between the groups (p= 0.31 and p =0.16, respectively).

Conclusion

In our population, prophylactic clipping after colorectal ESD did not significantly reduce the incidence of CSDB. These findings were confirmed even when the analysis was restricted to high-risk patients. Considering the technical challenges of complete clip closure, it could be reserved for selected clinical scenarios.

References

[1] Saito H, Igarashi K, Hirasawa D et al. The risks and characteristics of the delayed bleeding after endoscopic submucosal dissection for early gastric carcinoma in cases with anticoagulants. Scand J Gastroenterol 2020; 55: 1253–1260
[2] Boda K, Oka S, Tanaka S et al. Clinical outcomes of endoscopic submucosal dissection for colorectal tumors: a large multicenter retrospective study from the Hiroshima GI Endoscopy Research Group. Gastrointest Endosc 2018; 87: 714–722
[3] Bordillon P, Pioche M, Wallenhorst T et al. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021; 94: 333–343
[4] Probst A, Ebigbo A, Märkl B et al. Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center. Endoscopy 2017; 49: 222–232
[5] Albouys J, Montori Pina S, Boukechiche S et al. Risk of delayed bleeding after colorectal endoscopic submucosal dissection: the Limoges Bleeding Score. Endoscopy 2024; 56(2):110-118

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

Transport is a major contributor to the environmental impact of endoscopic procedures, including therapeutic ones like Endoscopic Submucosal Dissection (ESD). An ESD generates 73.2 kg CO₂e, with nearly half attributed to travel, notably for face-to-face consultations with endoscopists or anesthesiologists. Alternatives like virtual or local off-site consultations may reduce this burden. This study aimed to assess whether different consultation types affect ESD outcomes and to estimate the environmental benefit of using non-traditional formats.

Aims & Methods

We analyzed ESD procedures recorded from January to September 2024 in the FECCO prospective national database, which included details on consultation types and transport modes. Clinical parameters (age, ASA score, ESD effectiveness: success, en bloc, R0, curative; and safety: perforation, delayed bleeding, surgery for adverse events) and logistical data (consultation number/type, travel distance and mode) were collected. The main endpoint was the comparison of ESD outcomes and environmental impact based on the type of consultation. Three consultation types were compared: face-to-face in the distant resection center (FFD), face-to-face locally (FFL), and remote virtual (VR). Environmental data were derived from the RESECT post hoc study.

Results

Among 1809 ESDs, 1458 patients had FFD endoscopic consultations (85.4%), while 249 had VR (14.6%). Of 1747 patients with anesthesiology data, 1348 had FFD (77.2%), 359 FFL (20.5%), 36 VR (2.1%), and 4 had no consultation. Mean round-trip distances were 34 km for FFL and 175 km for FFD. Combined consultations accounted for 325,500 km and 65 tons CO₂e (36 kg/patient). Only 7/1481 (0.5%) used public transport. Since the procedure is performed exclusively in expert centers, it accounts for an additional 316,575 km of travel and 63 tons of CO₂e emissions (34.8 kg CO₂e per patient). No differences were found between FFD and VR groups in lesion size, location, CONECCT class, patient age, anticoagulant/antiplatelet use. ASA score was slightly lower in VR (2.12 vs 2.24, p=0.04). En bloc resection was 96.6% vs 96.0% (p=0.57), R0 resection 89.4% vs 92.7% (p=0.19). Perforation occurred in 7.6% vs 8.4% (p=0.76), surgery for adverse events in 1.22% vs 1% (p=0.99), and delayed bleeding in 5.9% vs 2% (p=0.04). ESD duration and resection speed were similar (60 min/36.4 mm²/min FFD vs 61 min/38 mm²/min VR, p>0.2).

Conclusion

ESD outcomes after teleconsultation are comparable to those following face-to-face consultation. Despite this, only 12% used teleconsultation, though it could save 36 kg CO₂e per patient. Optimizing care pathways to promote remote consultations could significantly reduce the environmental footprint of ESD.

Introduction

Despite undeniable advantages as higher en-bloc and curative resection rates, better carcinologic outcomes and lower recurrence rates, endoscopic submucosal dissection (ESD) is associated with more adverse events, than piece-meal endoscopic mucosal resection, limiting its spread in the West. However, risk factors in western patients and clinical implications of perforation are not well known.

Aims & Methods

This is a prospective cohort including all colorectal ESD performed in 12 French centers and 1 Belgian center between September 2019 and September 2022, with additional retrospective analysis of patients with per-procedural or delayed perforations.
The objectives of this study were to analyze prevalence, risk factors and clinical outcomes of perforation following colorectal ESD.

Results

Per-procedural perforations (PPP) (n=354) or delayed perforation (DB) (n=20) occurred in 374/4025 procedures, with a mean ±SD lesion size of 54 ±26 mm, and median procedure time of 57 min (IQR 34-90).
In the perforation group, lesions were larger (60 ±32 mm vs 53 ±25 mm, p= 0,001), with lower resection speed (25 ±21 mm2/min vs 35 ±24 mm2/min) and presented more severe fibrosis (55,5% vs 26,2%, p<0,0001). En-bloc (87,2% vs 95,8%), R0 (74,0% vs 89,0%) and curative resection (71,2% vs 85,2%) rates were lower in the perforation group (all p<0,0001).
Non-granular laterally spreading tumors (LST) was a risk factor of both PPD (p=0,036) and DP (p<0,0001). Female sex was associated with PPP (p=0,019) but not with DP (p=0,714).
PPP were more frequent in intermediate-volume centers compared to low and high volume (p<0,0001), but there was no difference regarding the risk of DP (p=0,949).
Poor manoeuvrability was associated with PPP (p<0,0001) but not with DP (p=0,351).
PPP were particularly frequent in the splenic (21/102 lesions, 19,0%) and hepatic (30/184 lesions, 16,3%) flexures and in the appendix (20/118, 16,9%), with statistical significance (p<0,0001). All DP occurred in the colon but there was no statistical difference between the different segments.
Prophylactic closure of the scar did not prevent DP (OR 1,22 95%CI 0,41-1,22).
By calculation of area under the curve (AUC), a threshold of ³ 70 mm was identified as predictive for immediate perforation (p<0,0001).
In multivariate analysis, lesion ³ 70 mm (OR 2,17 95%CI 1,50-3,15), speed of resection (OR 0,98 95%CI 0,97-0,99), female sex (OR 1,30 95%CI 1,01-1,68), poor maneuverability (OR 1,53 95%CI 1,15-2,03) and severe fibrosis (OR 3,2 95%CI 2,30-4,4,43) were predictive of PPP.
Regarding clinical burden, DP required surgery in most of the cases (17/20, 85%) whereas PPP were treated conservatively (13/354 emergent surgeries, 3,7%) (p<0,0001). Stoma was performed in 37,5% of cases. Among rectal perforations, no closure was done in 23% of cases without the need for surgical or radiological interventions.
In colonic PPP, the need for peritoneal exsufflation or the type of closure (TTS clips vs OTS clips) were not associated with surgery. CRP and white cell blood levels on day 1 after ESD were not different between groups but fever was associated with surgery (OR 9,41 95%CI 2,44-36,29).

Conclusion

In this large study, risk factors for per procedural perforations could be identified and conservative treatment appears effective. Delayed perforations are rare and cannot be predicted but require surgery in most of the cases. This could help the patient and the physician to choose the best treatment with balance of benefices and risks.

Introduction

Optical diagnosis attempts to guide the endoscopist in making a treatment choice, however, selecting lesions with possible covert cancer (CONECCT IIA lesions: JNET IIA, no macronodule, no depressed area), high-risk lesions (CONECCT IIC lesions: JNET IIB or macronodule or depressed area) or overt submucosal invasive carcinoma (SMIC) (CONECCT III lesions: JNET III area) remains challenging.

Aims & Methods

We aim to describe the endoscopic and oncologic outcomes of endoscopically removed T1-colorectal cancers (T1-CRC), according to their pre-resection classification by optical diagnosis. This is a multicenter prospective cohort study in 13 centers. Procedural and oncological outcomes were analyzed using univariate analysis.

Results

7495 colorectal ESDs were included from 09/2019 to 09/2024, with a median lesion size of 50mm [35-65], rectal location in 35.3% and right colon in 37.9%. Lesions were classified as CONECCT IIA in 28.4%, CONECCT IIC in 60.3% and CONECCT III in 5.3%. En-bloc, R0 and curative resection rates were 96.3%, 88.1% and 81.4%, with significant decreasing trends as the CONECCT classification advanced (97.3%; 91.9%; 90.7% in CONECCT IIA, 96.3%; 87.6%; 80.6% in CONECCT IIC and 93.2%; 74.2%; 32.0% in CONECCT III, respectively; p<0.001). T1-CRC occurred in 10.4% and the prevalence significantly differed according to the optical diagnosis: 2.3% in CONECCT IIA, 10.8% in CONECCT IIC and 49.6% in CONECCT III. En-bloc, R0 and curative resection rates were 96.7%, 74.9% and 23.6% respectively, with a significant decreasing trend in curative resection rates as the CONECCT classification increased (25.5% CONECCT IIA, 26.5% CONECCT IIC and 13.9% CONECCT III; p=0.002). Vertical margins were free in 80.3%. Overall median depth of SMIC was 1500µm [750-2560], measuring 1426µm in CONECCT IIA, 1840µm in CONECCT IIC and 2744µm in CONECCT III (p<0.001), corresponding to deep SMIC in 46.8% in CONECCT IIA, 62.2% CONECCT IIC and 77.1% CONECCT III (p<0.001). Lympho-vascular invasion and tumor budding were more frequently observed in CONECCT III at 30.0% and 34.3% respectively (vs 23.9%; 23.9% in CONECCT IIA and 16.4%; 20.6% in CONECCT IIC; p=0.002). Poor differentiation was reported in 5.3% with no significant difference between categories. Finally a trend was noted in the number of prognostic risk factors per lesion: no high-risk factors in 34.0% of CONECCT IIA, 29.5% in CONECCT IIC and 18.6% in CONECCT III, versus 3 high-risk factors in 4.3% in CONECCT IIA, 7.0% in CONECCT IIC and 11.2% in CONECCT III (p=0.049).

Conclusion

Endoscopic resection of T1-CRC demonstrates high en-bloc and R0 resection rates. However, curative outcomes and oncologic features worsen significantly with the presence of risky optical diagnostic criteria, highlighting the importance of adequate optical diagnosis and considering intramuscular resection techniques for advanced lesions, balancing over- and undertreatment as nearly 50% of CONECCT III lesions were T1-CRC.

References

Brule C, Pioche M, Albouys J, et al. The COlorectal NEoplasia Endoscopic Classification to Choose the Treatment classification for identification of large laterally spreading lesions lacking submucosal carcinomas: A prospective study of 663 lesions. United European Gastroenterol J, 2022;10():80-92