Introduction

Submucosal lifting agent is critical to perform endoscopic submucosal dissection (ESD) and even used sometimes in conventional endoscopic mucosal resection (EMR). ORISE Gel is a recently introduced and approved lifting agent in United States and Europe and one of the most used injection solutions for ESD. However, it has recently been revealed in some cases that ORISE Gel induces a foreign body reaction histologically. Most publications have been reported as case series from United States, but few from other countries. We aim to analyze the characteristic findings and clinical implications with Orise Gel injection and literature review to increase awareness.

Aims & Methods

We used a prospectively maintained ESD database at our center in Sweden between January 2020 and March 2023. Colorectal ESD or converted EMR during ESD (rescue EMR) specimens injecting ORISE Gel were included. The literature review included from PubMed between January 2019 to March 2023.

Results

A total of 99 cases (89 ESD or rescue EMR and 10 subsequent surgeries) were identified during the study period. There are 48 male and 51 female patients with a median age of 69.4 years.
Orise gel injection was used in 57 cases (57.6%). 8 cases had radiological follow-up because of T1 cancer. Of these, 5 cases underwent subsequent surgical resections, where the injection sites were in distal rectum in 3, cecum in 1 and descending colon in 1 case. The surgical resection specimens showed histopathologically T2 colorectal cancer in one, residual adenoma with low grade dysplasia in 2, and no dysplasia cell in 2 cases. All of them showed histologically extensive foreign body-type granulomatous giant cell reaction. These changes were detected in 3 cases by MRI or CT image with a sign of local wall thickness before surgical resections. This resulted in a clinical overdiagnosis of more advanced T-staging. Meanwhile, 3 cases were followed up by radiological imaging and 2 of them showed a similar change as local wall thickness, however both were diminished as time advanced.

Conclusion

This large Swedish case series raises the awareness that the submucosal lifting agent causes extensive histological reaction at the injection site in all surgical specimens. These changes are observed at the radiological follow-up. This gel deposits in the specimens may lead to a misinterpretation of a mass as tumor growth and they can change differently with time.

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

Piecemeal endoscopic mucosal resection (EMR) vs endoscopic submucosal dissection (ESD) has been a long standing debate in the endoscopic community worldwide with multiple studies done to evaluate the preferred method to manage large colorectal neoplasms. Piecemeal EMR with thermal ablation of the margin has been strongly advocated and reported by certain groups to be a simple, inexpensive and effective technique and this has been preferred widely due to its perceived ease of performance and shorter learning curve.¹ However, close, repeated surveillance colonoscopy is recommended even when the lesion is thought to have been completely resected² as residual tumors can cause interval cancers.³ Some groups, mainly from east Asian countries, have recommended en bloc resection by ESD due to significantly lower risk of local recurrence and precise pathological diagnosis.⁴ But its usage is limited due to concerns about risk of serious adverse events. With improvement in training and devices, colorectal ESD is now being performed by various centers globally. This study aims to report the outcomes of an international, multicenter study on colorectal ESD.

Aims & Methods

Patients who underwent colorectal ESD for lesions greater than 20mm between January 2022 to April 2024 from centers in USA, Japan, and India respectively were included in this study. Recurrent lesions after endoscopic therapy, neoplasms identified in patients with ulcerative colitis, and non-epithelial lesions were included. Primary outcomes were en bloc and R0 resection rate, delayed adverse events (bleeding/perforation), and local recurrence rate. Secondary outcomes were procedure time, lesion size, and pathology. Univariate and multivariate analysis were done to identify the risk factors for primary outcomes.

Results

309 patients (median size, 40(27.5-60)mm; location rectum 52.4%, left colon 26.2%, right colon 21.4%) were involved in this study. The en bloc resection rate was 96.1% and R0 resection rate was 90.3%. 3 patients experienced delayed bleeding which was managed endoscopically. 2 patients underwent surgery for delayed perforation. 6 patients had a local recurrence. 67(23%) patients had intramucosal carcinoma on pathology. Univariate analysis showed lesser procedure time (median(IQR) 145(80-236.25) vs 270(180-300) minutes, P= 0.005) and smaller lesion size (median(IQR) 40(26-56.25) vs 60(40-90) mm, P= 0.004) were significant factors for successful en bloc resection. However, lesser procedure time (median(IQR) 74(29.5-97.5) vs 150(82.5-240) minutes, P= 0.034) led to an increased delayed adverse event rate. Multivariate analysis using Cox regression showed en bloc resection (odds ratio 0.038; 95% confidence interval 0.003-0.421; P= 0.008) was an independent factor preventing local recurrence.

Conclusion

This international, multicenter study with data from three countries shows favorable outcomes for colorectal ESD for large lesions. The high en bloc and R0 resection rate, and low adverse event rate show increased global adaptation to this procedure. Reduced local recurrence is an added benefit. Data from a more centers globally will be valuable to establish ESD as the standard for large colorectal neoplasms.

References

1. Sidhu M, Shahidi N, Gupta S et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology. 2021 Jul 1;161(1):163-70.
2. Gupta S, Lieberman D, Anderson JC et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:463-485.e5.
3. Rutter MD, Beintaris I, Valori R et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018;155:909-925.e3.
4. Ohata K, Kobayashi N, Sakai E et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology. 2022 Nov 1;163(5):1423-34.

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 resection of lesions involving the appendiceal orifice is an alternative to surgery. Long term outcomes have not been determined.

Aims & Methods

To determine the long-term efficacy and safety of endoscopic resection of appendiceal lesions.
Retrospective analysis of the endoscopic resection of lesions with appendiceal involvement was performed in seven centers in Spain between January 2016 and July 2022. The technical success rate (complete macroscopic resection at index procedure), recurrence rate and short- and long-term complications were evaluated, including delayed appendicitis with a clinical follow-up of at least 12 months. The intra-appendicular extension of the lesion was described as superficial (visible appendiceal margin) or deep (if it was not possible to determine the appendiceal margin of the lesion before resection) and the circumferential extension was described according to the affected percentage.

Results

98 lesions with appendiceal involvement were treated, 73 had a clinical follow-up >12 months with a median follow-up of 26 months ([IQR]16-37 months). There were 35 lesions with deep intra-appendicular involvement and 63 with superficial appendiceal involvement, 64 with a circumferential involvement ≥50%. The median size of the lesions was 20mm([IQR]10-30mm) and 19(19%) had previous manipulation. Underwater endoscopic mucosal resection (UEMR) was performed in 53% of the lesions (24% by underwater cap-suction pseudopolyp formation, CAP-UEMR) with a technical success of 93% (49% en bloc and 51% piecemeal).
Among these cases, there were 7 incomplete resection, with 3 patients undergoing surgery and the remaining 4 undergoing endoscopic treatment during a subsequent session. Within the entire cohort, there were 3 cases of malignant histology: one low-risk pT1 which underwent surgery resulting in no residual cancer and negative lymph nodes, another low-risk pT1a (which chose follow-up and experienced no recurrence), and a third with suspected incomplete resection and pT2 cancer, necessitating surgery.
There were 6 intraprocedural bleeding and 2 delayed bleeding, all managed endoscopically. 45 patients completed at least 12 months of endoscopic follow-up (median 18, [IQR] 8-29months), showing recurrence in 12 cases (6 lesions with deep intra-appendicular extension), 8 (67%) treated endoscopically. There was 1 case of intraprocedural perforation, managed endoscopically.
Surgery was needed during follow-up in 7 additional cases [recurrence=3; pT2 cancer =1; pT1a =1; appendicitis=2 (at 11 months and 56 months post-endoscopic resection)], in total 10 surgeries were needed in the entire cohort.

Table 1- Baseline characteristics of patients and resected lesions

Conclusion

The endoscopic management of lesions involving the appendix may indeed prove effective and safe after following a minimum follow-up of 12 months, offering a viable alternative to surgery. It is important to note that delayed-onset acute appendicitis, though rare can be observed beyond 11 months post-procedure, although a casual mechanism cannot be proven.

References

1. Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017 Mar;49(3):270-297. doi: 10.1055/s-0043-102569. Epub 2017 Feb 17. PMID: 28212588.
2. Albéniz E, Pellisé M, Gimeno García AZ, et al; en nombre del Grupo Español de Resección Endoscópica de la Sociedad Española de Endoscopia Digestiva. Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions. Gastroenterol Hepatol. 2018 Mar;41(3):175-190. English, Spanish. doi: 10.1016/j.gastrohep.2017.08.013. Epub 2018 Feb 12. PMID: 29449039.
3. Mi Song E, Yang H, Jung Lee H, et al. Endoscopic Resection of Cecal Polyps Involving the Appendiceal Orifice: A KASID multicenter Study. Dig Dis Sci. 2017, 62, 3138–3148, DOI: 10.1007/s10620-017-4760-2.
4. Jacob H, Toyonaga T, Ohara Y, et al. Endoscopic submucosa dissection of cecal lesions in proximity to the appendiceal orifice. Endoscopy, 2016. 48(09): v23-v23. DOI:10.1055/S-0042-110396.
5. Schmidt A. Lesions at the appendiceal orifice- the Achilles’heel of endoscopic resection? Endoscopy, 2022. 54(01): 25-26
   DOI: 10.1055/a-1686-8800
6. Patel AP, Khalaf MA, Riojas-barrett M, et al. Expanding endoscopic boundaries: Endoscopic resection of large appendiceal orifice polyps with endoscopic mucosal resection and endoscopic submucosal dissection. World J Gastrointest Endoscp 2023, 15(5):386-396. DOI: 10.4253/wjge.v15.i5.386.

Disclosure

Dr Hugo Uchima collaborates as proctor with Erbe Spain and Olympus Iberia. Has received congress registration from Casen Recordati.

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) 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.