Introduction

Endoscopic submucosal dissection (ESD) is gaining popularity around the word. However, ESD remains a technically difficult, labor-intensive and time-consuming procedure.

Aims & Methods

Study aim: To describe first clinical experience with recently developed new endoscopic platform to facilitate ESD.
Methods: C¹ endoscopic platform (Lumendi LLC, Westport, CT, USA) is a flexible overtube with a balloon on its distal end and attached instrument channel. The C¹ was preloaded on top of any colonoscope and inserted into colon till pre-cancerous or early cancerous lesion is reached. After circumferential incision around the lesion was completed with a commercially available ESD knife, a specially designed flexible grasper (Lumendi LLC, Westport CT, USA) was advanced through the instrument channel. The separated edge of the lesion was grasped with the grasper to facilitate ESD. After completion of the ESD, C¹ was used a conduit to deliver Overstitch endoscopic suturing device mounted on a double channel upper endoscope (GiF 2T180, Olympus, Center Valley, PA, USA) to the site of lesion removal to perform sutured closure of the post-ESD defect.

Results

C¹ platform was used in 7 patients (3 females, 4 males, age 62.1±10.1 years) with large (35.0±13.5 mm) sessile colonic polyps. Most lesions were located in anatomically difficult positions (splenic and hepatic flexure, appendix and ileocecal valve). On-demand inflation of the C¹ balloon facilitated advancement of the colonoscope through the colon and shortening and straightening of the colonic turns. None of the patients required external pressure or a change of patient position and in all cases the colonoscope was successfully advanced to the cecum. When the lesion was reached, the balloon was distended providing stabilization of the colonoscope during ESD. Flexible grasper provided multidirectional dynamic retraction of the lesion making endoscopic dissection simple and fast (total ESD time 38.7±16.5 minutes with mean dissection speed 24.8 mm²/minute). After completion of dissection, the lesion was retrieved through C¹ and then Overstitch suturing device was easily delivered to the ESD site. Suturing closure of post-ESD defects was successfully achieved in all patients. There were no device related adverse events during the study.

Conclusion

Newly developed C¹ endoscopic platform with a flexible grasper significantly facilitates colonic ESD.

Introduction

The Double Balloon Endoscopic Platform (DBEP), DiLumen® EZ Glide (Lumendi Ltd, Maidenhead, UK), has been in clinical use since 2017. It has demonstrated safety and efficacy in facilitating diagnostic and complex therapeutic procedures in the colon, including patients with normal and surgically altered anatomy.

Aims & Methods

To evaluate the use of DiLumen® EZ Glide for diagnostic and therapeutic interventions within the small bowel.
The DBEP is a flexible overtube with two balloons at its distal end and is preloaded over a standard colonoscope. Once advanced into the sigmoid colon, the proximal (aft) balloon (rigidly attached to the overtube) is inflated to anchor the device within the colon. The device is then pulled back to shorten and straighten the sigmoid colon. Then the colonoscope is advanced to the next colonic segment, and the process of balloon inflation, retraction, and advancement is repeated until the cecum is reached and the assembly is directed through the ileocecal valve into the ileum. This technique is continued within the small bowel until the target lesion is reached for intervention.

Results

Seven patients (3 males, 4 females; mean age 59.7 ± 9.8 years) underwent ileal interventions using the DBEP. All procedures were technically successful (100%). The furthest advancement of the colonoscope was up to 6 feet proximal to the ileocecal valve. The mean size of small bowel lesions was 23.6 ± 11.4 mm.
Three patients had ileal polyps (30, 35 and 40 mm), all of which were removed en bloc: one by endoscopic mucosal resection (EMR) and two by endoscopic submucosal dissection (ESD). Pathology confirmed all polyps were benign, and no further treatment was required.
The remaining four patients had submucosal nodules (mean size 15.0 ± 4.1 mm, range 10–20 mm). Prior biopsies of this lesions covered by normal mucosa were non-diagnostic. All nodules were successfully removed en bloc (3 by ESD, 1 by EMR), and post-resection defects were closed using continuous suturing with the OverStitch™ endoscopic suturing system (Boston Scientific, Marlborough, MA, USA), delivered via the DBEP.
Histopathologic analysis revealed large B-cell lymphoma (1 patient) and well-differentiated neuroendocrine tumors (3 other patients). The lymphoma patient was treated conservatively with chemotherapy. All neuroendocrine tumor cases underwent robotic hemicolectomy with ileal resection. Pathological examination of surgical specimens revealed lymph node metastases (pN1) in all 3 patients.

Conclusion

Traditional endoscopic biopsy of ileal submucosal lesions does not provide adequate diagnostic value and cannot determine effective treatment plan. The DBEP significantly facilitates small bowel access and enables effective diagnostic and therapeutic endoscopic interventions inside the small bowel. In this early series, endoscopic excision of ileal lesions provided accurate histological diagnosis and directly influenced clinical management. Most importantly, our findings suggest that even early-stage (pT1 and pT2), well-differentiated ileal neuroendocrine tumors already had lymphatic spread, reinforcing the need for surgical resection despite complete local endoscopic excision.

Disclosure

Sergey Kantsevoy: Endosound - investor, Lumendi - consultant, equity, Medtronic - consultant, Olympus - consultant, Slater Endoscopy - consultant, equity, Vizballoons - consultant, equity.

Introduction

Screening colonoscopy has become the gold standard in discovery and removal of colonic polyps and prevention of colon cancer. However, in 13.1-25.8% of patients colonoscopy was not completed and cecal intubation was not achieved.^1-3 DiLumen® (Lumendi LLC, Westport CT, USA) double balloon endoscopic platform was developed to facilitate endoscopic interventions in gastrointestinal tract.

Aims & Methods

Aim: To evaluate use of DiLumen® to facilitate difficult colonoscopy.
Methods: DiLumen® is a flexible overtube with 2 balloons on its distal end. One (Aft) balloon is rigidly attached to the overtube and a second (For) balloon can be advanced forward or pulled back using 2 push rods moved by a slider located on the handle of DiLumen®. The assembled platform is pre-loaded on top of any colonoscope and introduced into the rectum. The colonoscope-DiLumen® assembly is advanced through sigmoid into descending colon where Aft-balloon is distended to fix the overtube inside the colonic segment. Then DiLumen® is pulled back to straighten and to shorten the colon. The colonoscope is advanced forward till transverse colon is reached. The Aft balloon is collapsed and DiLumen® is advanced into transverse colon over the colonoscope. The Aft balloon is distended inside the transverse colon and DiLumen® is pulled back now shortening and straightening the left colon. This process is repeated till the cecum is reached.

Results

We reviewed use of DiLumen® to facilitate colonoscopy in 53 patients (25 males, 28 females, mean age 68.0±10.1 years). Prior to referral for DiLumen®-assisted procedure, one colonoscopy attempt was unsuccessful in 31 patients, 19 patients had 2 unsuccessful colonoscopies, 2 patients had 3 unsuccessful colonoscopies and 1 patient had 4 unsuccessful colonoscopy attempts. The most common reasons for failure were long, redundant, torturous colons. DiLumen® effectively straightened and shortened the colon markedly facilitating advancement of the colonoscope and allowing successful examination of the entire colon with cecal intubation in all 53 patients (technical success 100%). Mean time to reach cecum was 13.1±6.8 minutes and total procedure time was 30.6±15.2 minutes. Normal colonic mucosa was seen in 13 patients (24.5%). Majority (75.5%) of patients had significant pathology found: only 1 polyp was found in 14 patients (26.4%), 2 polyps were found in 10 patients (18.9%), 3 and more (up to 9) polyps were found in 16 patients (30.2%). The polyps ranged in size from 3 to 80 mm and were found in all colonic segments from rectum to ileocecal valve.

Conclusion

Endoscopic double balloon interventional platform markedly facilitated colonic straightening and shortening and allowed successful completion of colonoscopy with removal of previously undetected colonic polyps in patients with difficult (long, redundant and torturous) colon and unsuccessful previous colonoscopies.

References

1. Witte TN, Enns R. The difficult colonoscopy. 2007 Aug; 21(8): 487–490.
2. Baxter NN, Goldwasser MA, Paszat L, Saskin R, Urbach DR, Rabeneck L. A population-based case control study of the effectiveness of colonoscopy for prevention of death from CRC. Gastroenterology. 2007;132:A–88.
3. Shah H, Paszat LF, Saskin R, Stukel TA, Rabeneck L. Factors associated with incomplete colonoscopy: A population-based study. Gastroenterology. 2007;132:2297–303.

Introduction

Endoscopic submucosal dissection (ESD) of anorectal junction lesions (ARJL) presents technical challenges. This location may be associated to increased risk of adverse events, such as anal stricture, fecal incontinence, and chronic pelvic pain. We aim to identify the safety and effectiveness of the ESD for ARJL.

Aims & Methods

We conducted a retrospective cohort study on consecutive patients undergoing ESD for rectal submucosal lesions between 2018 and 2023 at two centers. Patients without follow-up were excluded. Lesions were categorized as ARJL) or proximal rectal lesions (RL). Complications were assessed starting from 12 hours post-procedure.

Results

Our study included 61 patients (54% male; mean age 71±9 years). Forty patients had RL and twenty-one had ARJL. 89% of the patients had an R0 resection. 90% had en bloc resection. On histology 62% of the lesions were low-grade dysplasia adenoma, 16% were high-grade dysplasia adenoma, 7% had intramucosal adenocarcinoma and 15% had adenocarcinoma with submucosal invasion (T1), of which 33% had deep submucosal involvement (sm1), all RL. 3% were submitted to surgery. Mean procedure times were 95±63 and 128±117 minutes (p=0.21) with mean sizes of 36.72±16.31 mm and 36.94±25.16 mm (p=0.96), for RL and ARJL respectively. Median follow-up time was 18 months (IQR 7-39). In total, only five patients developed complications during follow-up: From the ESD of ARJL, 1 patient developed an asymptomatic stenosis and from the ESD of RL, one also developed an asymptomatic stenosis, two patients developed post-polypectomy syndrome, one had delayed bleeding and one had chronic pelvic pain.

Conclusion

Our study identified a low incidence of adverse effects associated with ESD of the ARJL, being categorized as mild, indicating favorable tolerability and safety of these interventions. Limitations include the retrospective design and small sample size. Further research is needed to validate these findings and to compare ESD and transanal surgery outcomes.

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

Endoscopic submucosal dissection (ESD) for the anal canal lesions (ACLs) is technically challenging because of the specific anatomical features of the anal canal. We aimed to evaluate the efficacy and safety of ESD for ACLs.

Aims & Methods

We retrospectively investigated 102 patients with ACLs who underwent ESD from August 2010 to August 2023. We collected and analyzed clinicopathological characteristics, procedure‑related parameters, outcomes, and follow‑up data.

Results

Of the 102 patients with ACLs (mean age 63 years, 46 men), ACLs were located above the dentate line (ADL) in 55 patients, and lesions involved the dentate line (IDL) in 47. The mean procedure duration was 37.0 min. The en bloc resection and en bloc with R0 resection rates were 94.1% and 88.2%, respectively. Adverse events (AEs) included two intraoperative bleeding, two delayed bleeding, and one febrile episode. Anal pain occurred in 5 patients. During a median follow-up of 37 months, local recurrence was revealed in 3 patients, and one had metastases. Compared with the ADL group, the IDL group had significantly longer procedure duration, larger specimens, lower rates of En bloc with R0 resection, higher anal pain rate, and more AEs. When only adenomas/adenocarcinomas were included in the analysis, the two groups had no significant differences regarding recurrence-free, overall, and disease-specific survival.

Conclusion

The favorable short‑ and long-term outcomes indicate ESD is a safe, effective, and attractive therapeutic modality for ACLs. A multicenter and prospective study should be conducted to validate this technology.