Introduction

In recent years, the prevalence of colonic diverticulosis has been increasing all over the world. Colorectal lesions are occasionally found in proximity to the diverticulum. There are generally considered pseudodiverticulum and lack a muscularis layer. Therefore, endoscopic resection (ER) for such lesions is often contraindicated because of the high risk of perforation. Recently, several studies have reported which such lesions were treated via endoscopic submucosal dissection (ESD). However, the usefulness and safety of ESD for lesions in proximity to diverticulum (D-ESD) has not been fully investigated.

Aims & Methods

Aim of this study was to evaluate the usefulness and safety of D-ESD. We defined that the D-ESD was ESD for lesion within 3mm of a diverticulum in this study. This study was performed at Kobe University Hospital and Kishiwada Tokushukai Hospital, which are tertiary referral centers in Japan, between January 2010 and April 2020. Totally, twenty-six consecutive patients who underwent D-ESD were enrolled. We used two strategic approaches for D-ESD, depending on whether submucosal dissection of the diverticulum-associated area was necessary (strategy B) or not (strategy A).
Strategy A was indicated for lesions that submucosal dissection including the diverticulum was not necessary because there was sufficient space between the lesion and the diverticulum for mucosal cutting. Strategy A was performed using the same technique as conventional ESD. Strategy B was indicated for lesions wherein sufficient space to make an incision could not be confirmed between the edge of the lesion and the orifice of the diverticulum. Strategy B used the pocket creation method (PCM), which provides stability of endoscopic manipulation and good countertraction to diverticulum part. The treatment outcomes and adverse events of the two strategic approaches were analyzed.

Results

Strategies A and B were applied in management of 17 lesions and 9 lesions, respectively. Most of lesions (23/26; 88.4%) were located in the right side of the colon. The median tumor size (range) was 33 (15-115) mm. As histological findings, A total of three adenomas, two sessile serrated lesions and 21 cancerous lesions were found. The cancerous lesions included 15 cases of intramucosal carcinoma, five cases of T1a, and one case of T1b. The median diverticular size (range) in all cases was 4 (3-10) mm. Except for one case in which ESD was discontinued because of the high risk of perforation due to deep tumor invasion into the diverticulum, all other cases were achieved en-bloc resection (25/26; 96.2%). The R0 resection and curative resection rates were 76.4% and 70.6% for Strategy A, and 88.9% and 77.8% for Strategy B, respectively. There was one case of lymphatic invasion in each of Strategies A and B. The median operative time was 69 minutes (24-140) for strategy A and 100 minutes (42-188) for strategy B. Regarding adverse events, two cases of intraoperative perforation and one case of delayed perforation occurred in the strategy A. On the other hand, no perforation was observed in strategy B, but two cases of post-electrocoagulation syndrome (PECS) were noted. There was no recurrence during the follow-up period (median duration: 24 months).

Conclusion

D-ESD achieved high en-bloc and R0 resection for both strategies. There were no cases of perforation in strategy B, which is considered to have a high risk of perforation. D-ESD may be a useful treatment option for such lesions.

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.

Introduction

Endoscopic resection of colonic tumors by endoscopic submucosal dissection (ESD) is now gaining worldwide acceptance. However, it is a technically challenging procedure with a delayed bleeding and perforation rate of 0.1-3.1% and 0.3-0.7% respectively.^{1, 2} Prophylactic closure of post endoscopic mucosal resection (EMR) defects in the right colon has been recommended to reduce adverse events.³But there is no consensus on post ESD closure. There have been many reports regarding prophylactic clip closure being beneficial to prevent delayed adverse events post colorectal ESD.^{4, 5} Though there is no data that exclusively evaluates colonic defects which may be more high risk than rectal defects due to thinner wall and intra- peritoneal location. Several endoscopic techniques are now available for closure of large mucosal defects.

Aims & Methods

This study aims to determine the impact of prophylactic closure on outcomes of colonic ESD and evaluate various closure methods. This is a retrospective, multicenter study which included consecutive patients undergoing ESD for resection of superficial colonic neoplasm from April-October, 2024. Rectal, ileo cecal valve, and appendiceal orifice lesions were excluded. Recurrent lesions, multiple lesions simultaneously treated, and lesions associated with inflammatory bowel disease were also excluded. Patients were allocated to closure and non closure groups which were compared using univariate analysis. Primary outcomes were delayed adverse events (bleeding and perforation), and duration of hospitalization. Sub group analysis was done to compare the closure methods used in this study.

Results

Total 271 patients were involved in this study where 190 patients (mean + SD age 63.5 ± 10.36 years, 92(48.4%) men) underwent post ESD closure and 81 patients (mean + SD age 65.4 ± 11.92 years, 32(40%) men) were in the non closure group. There were no significant differences in age, sex, location (Table), patients using anticoagulants (32(16.8%) vs 11(13.6%), P= 0.501), and patients having intraprocedural perforation/deep muscle injury in both groups (Table). The en bloc resection rate was 263/271 (97%) and R0 resection rate was 204/271 (75.3%). The mean specimen size of the closure group was significantly higher (Table). There was no significant difference in delayed adverse events (Table). The procedure time was higher in the closure group (median(IQR) 62(31.5-106.5) vs 37(25-57.75) minutes, P<0.001), but the duration of hospitalization was lesser (median(IQR) 1(0-5) vs 4(1-6) minutes, P<0.001). The closure methods used were endoclips only (n=125), clip with line pulley securing (CLiPS) technique ⁶ (n=54), X-tack (n=10), and overstitch (n=1). CLiPS technique was associated with shortest procedure time (median(IQR) 72(39.5-109) vs 38(24-57) vs 124.5(110.5-164.5) minutes, P<0.001). X-tack could close significantly larger defects (mean + SD 34.24 + 12.89 vs 40.47 + 14.78 vs 59.6 + 25.61 mm, P<0.001).

Conclusion

Prophylactic closure of post colonic ESD defects has no significant impact on delayed adverse events, but it reduces hospitalization time.

References

1. Fujishiro M, Yahagi N, Kakushima N, et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol. 2007;5(6):678 83.
2. Isomoto H, Nishiyama H, Yamaguchi N, et al. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy. 2009;41(8):679–83.
3. Ferlitsch M, Hassan C, Bisschops R, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline–Update 2024. Endoscopy. 2024 Apr 26.
4. Omori J, Goto O, Habu T, et al. Prophylactic clip closure for mucosal defects is associated with reduced adverse events after colorectal endoscopic submucosal dissection: a propensity-score matching analysis. BMC gastroenterology. 2022 Mar 26;22(1):139.
5. Liu M, Zhang Y, Wang Y, et al. Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta‐analysis. Journal of Gastroenterology and Hepatology. 2020 Nov;35(11):1869-77.
6. Minato Y, Ohata K, Kimoto Y, et al. A modified approach for closing endoscopic submucosal dissection defects using clip with line pulley securing technique and endoloop. VideoGIE. 2024 Jul 1;9(7):320-3.
   

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) is a valuable technique for the en-bloc resection of superficial neoplasms in the anal canal. However, its safety and efficacy in patients who have previously undergone transanal endoscopic surgery (TES) —such as transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM)—remain unclear.

Aims & Methods

To assess the safety and outcomes of ESD in the anal canal for patients with a history of TES compared to naïve patients.
A retrospective analysis was conducted at our tertiary center on 51 patients who underwent ESD in the anal canal between March 2010 and November 2024. Patients with a history of transanal endoscopic surgery were compared to those undergoing ESD as their primary treatment. Key parameters, including resection speed, perforation rates, coagrasper usage, inpatient status, late hemorrhage, and recurrence, were evaluated. Statistical analysis was performed to determine significant differences between groups.

Results

Histological examination confirmed the following cases: 3 adenocarcinomas (including 1 non-curative ESD), 15 adenomas with high-grade dysplasia, 11 adenomas with low-grade dysplasia, 2 sessile serrated lesions, 15 sessile serrated lesions with dysplasia, 2 high-grade intraepithelial lesions, 2 low-grade intraepithelial lesions.
The median resection velocity was slightly lower in patients with recurrence (16.01 mm²/min) compared to those without recurrence (25.56 mm²/min), though this difference did not reach statistical significance (p = 0.062). Perforation occurred in 9.62% of cases, with similar rates between groups (p = 0.58), suggesting that prior TEM does not significantly increase the risk of this complication. Late hemorrhage was observed in 7.84% of patients, again without a significant difference between groups (p = 0.29).
The only statistically significant finding was the smaller lesion size in patients with recurrence (1,162 mm² vs. 2,250 mm², p = 0.045). This is likely due to intensive post-TEM surveillance, which allowed for early detection of recurrence before lesions could grow larger. Other factors, including sex, age, use of coagrasper during the procedure, en-bloc resection, R0 status, and inpatient admission rates, showed no significant differences between groups.

Conclusion

ESD in the anal canal after prior TES appears to be a safe and feasible procedure, with outcomes statistically comparable to those in naïve patients. Although absolute numbers suggest differences, particularly in lesion size, these findings may be influenced by the small sample size. Larger studies are needed to confirm these results and further evaluate long-term efficacy.

Introduction

Little is known on the outcomes of endoscopic submucosal dissection (ESD) in patients with recurrent lesions after surgical local excision (transanal endoscopic surgery TES, transanal endoscopic microsurgery TEM, transanal minimally invasive surgery TAMIS) of superficial rectal neoplasms (1). We aimed to evaluate the feasibility, safety and efficacy of ESD for incomplete or recurrent rectal neoplastic lesions after transanal surgery.

Aims & Methods

This multicenter retrospective study assessed 38 patients who underwent ESD between June 2016 and February 2022 for recurrent or incompletely resected after TES or TEM. Treatment outcomes were evaluated. Primary outcome was the non-recurrence tumoral lesion at first endoscopic follow-up control. Secondary outcome were En bloc resection, R0 resection, curative resection.

Results

Main results are given in Table 1. There were 16 male and 22 female patients. Median age (range) was 68.7 (44–88) years. Seventy-four percent of lesions were located in the lower rectum, and 55% reached the pectineal line. Sixty-one percent of lesions were laterally spreading tumor granular type (LST-G), and 34% were polyps. Forty-four percent of lesions were 0-IIa, and 23% were 0-Is according to the Paris classification. Seventy-one of lesions were Sano II, and 45% of lesions were Kudo IV. The median size of lesions (range) was 44 mm (10-100). Sixty-six percent of ESD were performed starting with full circumferential incision. Median operation time (range) was 79 (10–270) minutes. Thirty-nine percent of lesions has low vascular supply. Severe fibrosis was present in 78%of lesions. Ninety-two percent of lesions were successfully resected en bloc. R0 resection and curative resection rates were both 68%. Rectal fat is visualized in eleven patients, none of them requiring a surgery. Four post-operative bleeding and two stenosis occurred. Median (range) hospital length of stay after ESD was 1.8 days (0-4). Pathological examination revealed 32 adenomas (23 with low-grade dysplasia, 9 with high-grade dysplasia) and 3 adenocarcinomas (3 T2; there was no Tis or T1). All patients were followed up with endoscopic control after ESD, with biopsy samples if residual or recurrent tumor.Median (range) of follow-up period until first endoscopy control was 6.2 (1-13) months. « Only one residual lesion (one of three non-en bloc resections) actually showed low-grade dysplasia adenoma at follow-up.

Conclusion

ESD for incomplete or recurrent superficial rectal neoplastic lesions after transanal surgery (TEM,TES, TAMIS) is highly feasible and safe, and allows curative resection in a vast majority of cases.

References

1) Ikezawa N, et al. Digestion. 2021;102(3):446‑52.