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.

Introduction

The prevalence of musculoskeletal disorders (MSDs) among endoscopists is frequent. The aim of this study was to evaluate biomechanical risk factors for MSDs in gastroenterologists performing ESD.

Aims & Methods

An observational study was performed among interventional endoscopists performing ESD in 3 French centers. The physical constraints were assessed using an analog scale of perceived physical effort intensity and physiological sensors to measure joint angulation kinematics and muscle activity levels (flexor and extensor carpi radialis muscles) during diagnostic colonoscopy and ESD. High muscle strain was defined as any muscle activation exceeding 10% of the maximum voluntary contraction (MVC). Two distinct sub-tasks of ESD were identified: lesion marking and circumferential incision phase (ESD-1) and dissection phase (ESD-2).

Results

Six interventional gastroenterologists participated in the study. Perceived physical effort was significantly greater for ESD compared to colonoscopy (p = 0.03). Time spent at more than 10% MVC for the right extensor carpi radialis was significantly higher during ESD-1 than during colonoscopy (+15%, p=0.04). The greatest strain was observed in the left extensor carpi radialis. This muscle was particularly exposed since more than 50% of the time was spent at more than 10% of MVC during colonoscopy and up to more than 80% during ESD-1 and -2. Time spent in the neck flexion risk zone was significantly higher during ESD-2 than during colonoscopy (+42%, p = 0.046).

Conclusion

ESD increased the risk of musculoskeletal strain. It is crucial to develop prevention programs to reduce the risk of MSD in the gastroenterologist population.

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

Colorectal endoscopic submucosal dissection (ESD) is not widely performed in western countries due to technical complexity, risk of adverse events, and procedure time. Hybrid ESD (H-ESD) - partial submucosal dissection followed by snare-assisted resection – may be useful to achieved endoscopic resection in difficult situations. In our center we use H-ESD as rescue therapy during conventional ESD in case of unstable position, inability to achieving appropriate and safe knife angle, advanced submucosal fibrosis or thin submucosal layer and patient instability.

Aims & Methods

We retrospectively analyzed colorectal ESD performed in our centre between January 2014 and March 2023, colorectal lesions in inflammatory bowel diseases were excluded. Univariate and multivariate analyses were conducted to examine factors that may have influenced switch to H-ESD.

Results

A total of 281 colorectal ESDs for superficial neoplasms in 276 patients were considered. 160 patients (58%) were male with an average age of 68,9 years. In 55 (19,6%) cases ESD was switch to H-ESD.. 171 lesions were located in the colon (60.8 %) and 110 (39.1%) in the rectum; mean maximum diameter of the neoplasms was 35,9 mm (SD 18,4 mm). En bloc resection and complete resection (en bloc resection and R0) were achieved in 259 (92 %) and 245 (86 %) cases respectively.
On univariate analysis, the use of waterjet system-assisted knife (OR 0,3; 95% CI 0,17-0,57), underwater-ESD (OR 0,24; 95% CI 0,09-0,63), rectal localization (OR 0,17; 95% CI 0,07-0,40) and granular laterally spreading morphology (OR 0,40; 95% CI 0,21-0,75) were significantly associated to the achievement of complete ESD. Proximal colon localization (OR 3,9; 95% CI 2,08-7,30), severe submucosal fibrosis (OR 4,9; 95% CI 2,51-9,63), non-granular laterally spreading morphology (OR 2,31; 95% CI 1,27-4,21) and maximum diameter < 40 mm (OR 3,91; 95% CI 1,83-8,38) were related to the switch to H-ESD. On multivariate analysis only waterjet system-assisted knife use and U-ESD were significantly correlated with achievement of complete ESD; severe submucosal fibrosis and proximal colon localization resulted significantly related to the switch to H-ESD.

Conclusion

The use of waterjet system-assisted knife and underwater technique reduce the need to switch to H-ESD during endoscopic submucosal dissection of superficial colorectal lesions. Severe submucosal fibrosis and proximal location are risk factors for the need for the H-ESD switch.

Introduction

Endoscopic closure of mucosal defects following colorectal endoscopic submucosal dissection (ESD) helps prevent delayed complications. The Sure Clip Traction Band, a recently developed traction device for endoscopic procedures, features a silicone ring attached to the clip's base, allowing for traction between clips. We have developed a traction-band-assisted endoscopic closure (TBEC) method using the Sure Clip Traction Band [1]. In TBEC, tension between the clips at both ends of the mucosal defect narrows the defect, facilitating the placement of additional clips.

Aims & Methods

We conducted a prospective study to evaluate the feasibility of TBEC in colorectal ESD. Patients with 20-50mm colorectal neoplasms were enrolled. Patients underwent TBEC following the completion of ESD. The primary outcome was the complete closure rate. Secondary outcomes included closure time, number of devices required, and complication rate. The sample size was calculated to be 34 cases based on previous data.

Results

Thirty-four patients were enrolled across three institutions. Data are shown as median (IQR), if applicable. The median age was 75 years (72-80), with a male-to-female ratio of 19:15. Lesion locations were the right colon, left colon, and rectum in a ratio of 22:10:2, respectively. The median lesion diameter was 30 mm (25-35). All ESDs achieved en-bloc resection. The complete closure rate was 100% (34/34). The median closure time was 15 minutes (10-22). The number of devices used was one (1-2) traction band and eight (7-10) clips. Procedure-related complications included intraoperative perforation in 5.8% (2/34), delayed bleeding in 2.9% (1/34), and post-ESD electrocoagulation syndrome in 3.1% (1/32, excluding intraoperative perforation).

Conclusion

A high complete closure rate of mucosal defects following colorectal ESD was achieved using TBEC. Further studies are required to verify the efficacy of TBEC in preventing delayed complications.

References

[1] Maehara K, Esaki M, Sumida Y, Fukuda SI, Minoda Y, Ihara E, Akiho H. Complete closure of mucosal defect after colonic endoscopic submucosal dissection using clip with a silicone traction band. Endoscopy. 2022 Dec;54(S 02):E1005-E1006. doi: 10.1055/a-1889-4838. Epub 2022 Aug 4. PMID: 35926530; PMCID: PMC9736829.

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)