Introduction

Post-ESD coagulation syndrome (PECS), which reveals abdominal pain, inflammation or fever without perforation after ESD, is a recognized complication of colorectal ESD; however, prevention of PECS remains unknown. In our previous RCT, clipping closure after colorectal ESD did not reduce the incidence of PECS (Gastrointest Endosc. 2020: 859-867). The maXium unit is a new electrosurgical unit, which is expected to reduce tissue damage during ESD.

Aims & Methods

We conducted a prospective study (NewPEC study) to assess usefulness of the maXium unit for the prevention of PECS. The NewPEC study is a single-center, prospective cohort study, and patients who will undergo ESD for superficial colorectal neoplasms were prospectively enrolled. All participants routinely received computed tomography (CT) scan and blood examination on day 1 after ESD and pain severity was assessed on day 1-3 after ESD using visual analogue scale (VAS). PECS was defined as VAS ≥30mm, a raise of VAS ≥20mm from baseline, BT ≥37.5ºC or WBC ≥10,000/μl after ESD. The PECS was classified into type I, conventional PECS without extra-luminal air and type II, PECS with peri-luminal air. The primary endpoint of this study was the incidence of PECS. The pre-planned sample size for the analysis was 92 patients by estimating that upper limit of 90% CI for the PECS rate is less than 15% that is a threshold based on the previous RCT, with β errors of 0.20.

Results

Prior to the initiation of the present study, electrical circuit analysis was performed, and the maXium unit allowed submucosal dissection with lower power than with the VIO300D unit. From October 2019 to September 2021, 173 patients who undergo colorectal ESD were screened, 104 patients with inclusion criteria were enrolled in the primary enrollment, and finally, 92 patients were analyzed after excluding 12 patients in the present study. Median tumor size was 22mm. Final pathological diagnosis was 7 in SSL, 47, in adenoma, 24 in pTis CRC, 13 in pT1 CRC and 1 in pT2 CRC. The PECS rate was 15% [90%CI, 10-24%], including 10 % in the type 1 and 5 % in the type 2. The simple peri-luminal air without PECS was observed in 7 patients (8%). One patient revealed delayed perforation post-ESD day1, who underwent emergency surgery. As for the incidence of PECS, experienced skill was only significant factor for reducing the risk of PECS.

Conclusion

A new electrocoagulation system, maXium unit, did not reduce the incidence of colorectal PECS, compared to the historical control. However, the maXium unit showed equivalent results to the VIO300D unit that was used in the previous RCT.
(University Hospital Medical Network Clinical Trials Registry, Number: UMIN000038049)

Introduction

Colorectal endoscopic mucosal resection (EMR) is the treatment of choice for large colorectal lesions, but it has an important recurrence risk, requiring endoscopic surveillance. This study aims to identify factors associated with relapse and complications, by analysing the 5-year follow-up.

Aims & Methods

Prospective cohort study conducted in a single centre, including all patients submitted to colorectal pEMR between 2009 and 2021 with follow-up ≥3 months. We analysed lesion characteristics, calculated Sydney EMR recurrence tool (SERT) and SMSA (size, morphology, site, access) scores and compared complication and recurrence rates and respective risk factors.

Results

Included 568 mucosal resections, median age 69.5 years (IQR 62.3-76.0), male sex 58.1%. From the lesions included: 32.6% ≥40mm; 51.6% plane and 48.4% sessile; 35.9% in the right colon, 27.6% in the rectum, 23.2% in the transverse colon and 13.2% in the left colon. The median SMSA score was 4 (IQR 3-4) and median SERT score 1 (IQR 0-2), complication rate of 7.0% (bleeding, n=33; perforation, n=4; post-polypectomy syndrome, n=3) and overall recurrence rate of 20.3%: 15.1% in 3 months, 6.3% in 12 months, 2.5% in 36 months and 0% in 60 months.
The variables associated with recurrence were size ≥40mm (35.0% vs. 14.6%, p<0.001), anal location (35.1% vs. 19.7%, p<0.01), SERT score>0 (27.5% vs. 11.8%, p<0.001) and SMSA score=4 (30.6% vs. 11.5%, p<0.001), but not argon plasma therapy (22.8% vs. 18.7%, p=0.26). By logistic regression, size ≥40mm was associated with higher recurrence, but not statistically significant (OR 3.19, CI95% 0.69-1.63).
Use of anticoagulant/antiplatelet drugs was associated with higher risk of complications (12.7% vs. 4.7%, p<0.001), particularly bleeding (11.4% vs. 4.2%, p<0.01), with no difference for size ≥40mm (9.2% vs. 6.0%, p=0.17) or SMSA score=4 (7.6% vs. 6.5%, p=0.61).

Conclusion

The 5-year surveillance proved colorectal EMR’s efficacy. Recurrence is higher in lesions ≥40mm, with anal location, SERT score>0 and SMSA score=4, whereas bleeding is more frequent with the use of anticoagulant/antiplatelet drugs.

Introduction

Colorectal endoscopic submucosal dissection (ESD) is now widely performed and has become a standard procedure even at core hospitals throughout regional areas. As a minimally invasive treatment, it is frequently applied to elderly patients; however, it is crucial to determine whether such treatment can be achieved safely and effectively across an entire region, especially considering the presence of comorbidities or frailty and the risks associated with limited life expectancy.

Aims & Methods

This study aimed to evaluate the safety and efficacy of colorectal ESD for elderly patients in the Hiroshima region. We used a prospective registry of all colorectal ESD cases performed between August 2013 and December 2018 at 11 core hospitals in the Hiroshima area. Patients were categorized into an elderly group (≥75 years) and a non-elderly group (<75 years). Short- and long-term outcomes were compared between the two groups. Patients with advanced colorectal cancer, inflammatory bowel disease, familial adenomatous polyposis, or missing data were excluded.

Results

A total of 2,226 patients with 2,332 lesions were included: 684 patients with 716 lesions in the elderly group and 1,542 patients with 1,616 lesions in the non-elderly group. Baseline characteristics (elderly/non-elderly) were as follows: proportion of male patients was 56%/61% (P=0.024), median age was 79/66 years (P<0.001), and prevalence of comorbidities was 54.4%/35.7% (P<0.001), including cardiovascular disease (17%/7%), cerebrovascular disease (10%/5%), diabetes (17%/13%), pulmonary disease (9%/4%), hepatic disease (5%/3%), and other organ cancers (18%/12%). Antithrombotic drug use was 26%/11% (P<0.001). Regarding lesion characteristics, lesion location (right colon/left colon/rectum) was 52%/21%/28% vs. 53%/21%/27% (P=0.858), and median lesion size was 30 mm vs. 25 mm (P=0.066). Procedural outcomes were as follows: en bloc/piecemeal/interrupted resection rates were 96%/3%/1% vs. 96%/3%/1% (P=0.998), median procedure time was 65 min vs. 60 min (P=0.025), intraoperative perforation occurred in 3%/3% (P=0.594), delayed bleeding in 2%/2% (P=0.816), delayed perforation in 0.3%/0.4% (P=0.903), and emergency surgery in 0.6%/0.4% (P=0.523). Histopathological diagnoses were adenoma/pTis/pT1a/pT1b in 36%/46%/7%/11% vs. 38%/44%/7%/11% (P=0.830), with poorly differentiated histology of 0.1%/0.2% (P=0.652), lymphovascular invasion 6%/7% (P=0.543), tumor budding 3%/3% (P=0.765), positive vertical margin 8%/7% (P=0.161), and curative resection 81%/83% (P=0.484). Among non-curatively resected lesions, additional surgical resection was performed in 42% (56/134) vs. 64% (181/283) (P<0.001), and lymph node metastasis was detected in 10% (6/56) vs. 12% (22/181). During a median follow-up of 62 vs. 64 months, disease-specific death occurred in 3 vs. 2 patients, and death due to other causes occurred in 93 vs. 69 patients. The 5-year overall survival rate was 87.3% vs. 96.1% (P<0.001), and the 5-year disease-specific survival rate was 99.6% vs. 99.9% (P=0.114). Recurrence (local/distant) occurred in 1.3% (0.7%/0.6%) vs. 0.4% (0.2%/0.2%) (P=0.014), and the 5-year recurrence-free survival rate was 98.5% vs. 99.6% (P=0.010).

Conclusion

Although elderly patients had a higher baseline risk due to comorbidities and use of antithrombotic agents, colorectal ESD achieved favorable short- and long-term outcomes comparable to those in non-elderly patients. This study demonstrates that colorectal ESD was safely and effectively implemented throughout the Hiroshima region.

Introduction

Colorectal endoscopic submucosal dissection (ESD) is more difficult than gastric/esophageal ESD from anatomical aspects. Post-ESD complications, such as post-hemorrhage and perforation, have been frequently reported. In particular, a post-ESD complication, post-ESD electrocoagulation syndrome (PECS), may lead to delayed perforation. A previous study reported that risk factors for PECS were a long duration of treatment (≥90 min), specimen diameter (≥30 mm), and right colonic lesion¹⁾. However, no risk factor has been established, and risk factors remain controversial.

Aims & Methods

Our purpose was to clarify risk factors that can be unitarily explained with respect to PECS after colorectal ESD and achieve adequate postoperative management. Patients with fever (≥37.5°C) or a leukocyte count of ≥10,000/mL during admission and a visual analogue scale of ≥3 cm or 2 cm or longer increase from the baseline were regarded as having PECS. A total Joule heat load of ≥15389 J on a tumor during ESD was regarded as high Joule heat ²⁾. Joule heat was measured using a special device. For multivariate analysis, logistic regression analysis was used.

Results

We conducted a prospective observational study in 84 patients who underwent colorectal ESD at two facilities between January 2021 and March 2023. The median age was 70 years, and there were 63 males (75.0%). PECS occurred in 12 patients (14.3%). The only independent factor associated with PECS was high-level Joule heat (odds ratio: 7.28, 95%CI: 1.9-27.5, p<0.01). PECS was not associated with a long duration of treatment, large specimen diameter, or right colon.

Conclusion

Previously reported risk factors for PECS were associated with difficulties in performing colorectal ESD. In patients in whom tumor peeling is difficult, the heat load on a peeled surface increases, and PECS may readily occur. An index of high-level Joule heat made it possible to unitarily explain risk factors, such as a long duration of treatment, specimen diameter, and right colon, as risk factors for PECS. The total Joule heat can be quantified, facilitating the prediction of PECS onset.

References

1) Qiu J et al. Expert Rev Gastroenterol Hepatol. 2022;16:1079-1087.
2) Ochi M et al. World J Gastroenterol. 2021;27:6442-6452.