Introduction

Adenomas in the gastrointestinal tract are pre-malignant lesions that require complete excision for prevention of cancers. Conventional endoscopic techniques to remove these lesions involve either endoscopic mucosal resection or endoscopic submucosal dissection (1). Adenomas with submucosal fibrosis secondary to underlying tattoo, predisposing anatomical position and/or recurrence pose significant challenges in complete resection with higher rates of recurrent disease (1,2). With advances in third space endoscopic techniques, Hybrid approach involving combined EMR/ESD techniques or use of full-thickness resection devices have been described for en bloc resection of adenomas. However, especially in the West, there are times when piecemeal EMR is initiated and submucosal fibrosis is encountered prohibiting adequate snare engagement. We demonstrate five cases where this problem was overcome using submucosal incision and release using tip of the snare to perform salvage piecemeal EMR in the colon and duodenum.

Aims & Methods

In regards to the method, after the lesion with underlying submucosal fibrosis resistant to snare engagement has been identified, submucosal injection to areas surrounding the lesion using our standard polypectomy injectate was performed. Followed by mucosal incision to release and isolate the fibrotic areas using tip of the snare. After which we then employed standard polypectomy techniques to complete the EMR.

Results

The video showcases five cases of polyps in different regions of the colon that were treated with endoscopic mucosal resection (EMR) technique. The first case involved a transverse colonic polyp with an underlying tattoo that had fibrosis, making snare resection difficult. In the second case, a fibrotic polyp at the anal verge was resected by performing snare tip mucosal release to the anal margin on the lesion. In the third case, a recurrent polyp at the hepatic flexure had a fibrotic component that was resistant to submucosal lift. The fourth case involved an ascending colon polyp that had an area of submucosal fibrosis resistant to snare placement. The fifth case involved a large circumferential duodenal polyp that had fibrosis.

Conclusion

In conclusion Precut mucosal incision using snare-tip during piecemeal EMR when faced with resistant submucosal fibrosis is a cost effective and promising technique when standard approach is difficult. Further studies are required to compare its efficacy in regards to rate of adverse events and recurrence rates in comparison to other existing hybrid techniques. In our western practice, where ESD often is not the first-line option for adenoma resection, this technique allows clinicians to address the problem at hand without rescheduling or converting the procedure which has implications on timing, cost, and technical expertise of the endoscopy team.

References

1. Moss A, Bourke MJ, Tran K, Godfrey C, McKay G, Chandra AP, Sharma S. Lesion isolation by circumferential submucosal incision prior to endoscopic mucosal resection (CSI-EMR) substantially improves en bloc resection rates for 40-mm colonic lesions. Endoscopy. 2010 May;42(5):400-4.
2. Rashid MU, Alomari M, Afraz S, Erim T. EMR and ESD: Indications, techniques, and results. Surg Oncol. 2022 Aug;43:101742.

Introduction

Gastric fundus is a technically difficult area for endoscopic submucosal dissection(ESD), even for experienced endoscopists, due to its anatomic features, thin wall, and abundant blood supply.

Aims & Methods

To evaluate the feasibility a novel ESD technique, the “topflight ESD” for the gastric fundus tumors resection.
Topflight ESD procedure: marking dots are applied 5 mm outside the lesion margins, using the tip of the ESD knife; a mucosal incision is made in the distal esophagus, ca 3 cm above gastroesophageal junction; a tunnel is created into the gastric wall; subepithelial injection is performed using an endoscopic needle and the water flush from the ESD knife; extensive dissection of the submucosal space in the fundus and proximal corpus is performed; the tumor is isolated from the surrounding tissues; the endoscope is removed from the submucosal tunnel and is inserted into the gastric lumen; mucosal incision is performed outside the dots rim using the ESD knife; en bloc resection is obtained, the specimen is retrieved; finally, the esophageal incision is closed using conventional through-the-scope clips.

Results

An 81-year-old male patient with history of a coronary bypass surgery, right lung lobectomy and MALT lymphoma, was referred to us. On a previous gastroscopy, a 6 cm flat lesion with no ulcer(Paris 0-IIa+b), was identified in the gastric fundus and greater curvature of the proximal body. Biopsies revealed a mixed type, moderately differentiated adenocarcinoma. After multidisciplinary team conference a decision for ESD resection was made. The ESD was performed according to the steps described above. After lesion characterization, marks were placed around the lesion. Then, an incision was made in the distal esophagus and a wide tunnel was created, dissecting the submucosa under the lesion. Then, a mucosal incision from the luminal side was made. During this stage there was a 3mm perforation, highlighting the risk of perforation when the cutting is done from the luminal side. That perforation was effectively closed with the use of through-the-scope clips. En bloc resection was achieved. The esophageal incision was closed. The obtained specimen was 75x50mm in size. Oral liquids were started on day 1 and the patient was discharged asymptomatic, on day 2. The pathological examination confirmed the presence of a mixed type, moderately differentiated adenocarcinoma SM2L0V0R0, pT1b. The patient was under clopidogrel and was admitted at day 10 due to bleeding from the ESD ulcer, treated endoscopically, and remains asymptomatic 2 months after.

Conclusion

We demonstrate a novel and minimally invasive endoscopic option that uses conventional ESD devices. To our best knowledge, this is the first report of gastric fundus epithelial tumor resection using this technique. The Topflight ESD might be considered in such cases in the future.

References

1. Hamada K, Horikawa Y, Koyanagi R, Shiwa Y, Techigawara K, Nishida S, Nakayama Y, Honda M. Usefulness of a multibending endoscope in gastric endoscopic submucosal dissection. VideoGIE. 2019 Oct 19;4(12):577-583.
2. Kitamura M, Miura Y, Shinozaki S, Yamamoto H. The pocket-creation method facilitates gastric endoscopic submucosal dissection and overcomes challenging situations. VideoGIE. 2021 May 28;6(9):390-394.
3. Baldaque-Silva F, Vilas-Boas F, Velosa M, Macedo G. Endoscopic submucosal dissection of gastric lesions using the "yo-yo technique". Endoscopy. 2013;45(3):218-21.
4. Baldaque-Silva F, Wang N, Rouvelas I, Omae M. Traction-assisted endoscopic submucosal dissection of a duodenal gastrointestinal stromal tumor. Endoscopy. 2022 Jun;54(6):E318-E319.
5. Omae M, Wang N, Löhr JM, Vujasinovic M, Baldaque-Silva F. Endoscopic submucosal dissection by using a new traction device. VideoGIE. 2021 Oct 27;6(12):543-545.
6.Baldaque-Silva F, Wang N, Omae M. Duodenal subepithelial neuroendocrine tumor removed by endoscopic submucosal dissection using internal traction with magnets. VideoGIE. 2022 Apr 23;7(7):259-261.

Introduction

For the removal of diminutive colorectal polyps <10mm cold snare (CS) resection is standard of care. For polyps ≥20mm endoscopic mucosal resection (EMR) with a hot snare (HS) is recommended, which is usually accomplished in piece meal technique¹. Recently, a retrospective trial showed a favorable safety profile and a comparable recurrence rate for CS-EMR in comparison to HS-EMR for sessile serrated adenomas (SSA) ≥20mm². We investigated if CS-EMR is superior to HS-EMR for the removal of larger, non-pedunculated, colorectal polyps.

Aims & Methods

In this prospective, randomized, controlled trial non-pedunculated colorectal polyps ≥20mm were randomly assigned to CS-EMR or HS-EMR. Primary endpoint was major complication (=perforation or clinically significant post-endoscopic bleeding (CSPEB)), secondary endpoints were intraprocedural bleeding (IPB), postpolypectomy syndrome (PPS), technical success, resection speed and recurrence rate after 4 months.

Results

394 polyps were finally enrolled for intention-to-treat analysis. Rates of major complication were significantly lower in the CS-EMR group with 1.0% vs. 8.0% (p=0.001) including rates of perforation of 0% vs. 4.0% (p=0.007) and rates of CSPEB of 1.0% vs. 4.5% (p=0.038). Independent predictor for major complication in uni-/multivariable regression analysis was polyp size (OR 1.10).
Rates of IPB were 14.0% for CS-EMR and 22.9% for HS-EMR (p=0.023), rates of PPS 3.1% and 4.5% (p=0.478). Rates of technical success were 92.2% in CS-EMR group and 97.5% in HS-EMR group (p=0.017), resection speed was 22.61 (±16.62) cm²/h and 21.71 (±19.27) cm²/h (p=0.248) and recurrence rates 24.8% for CS-EMR and 15.0% for HS-EMR (p=0.037). In subgroup analysis a significant difference was observed for the recurrence rate of Laterally spreading tumors (LST) nodular-mixed type (43.8% vs. 16.7%, p=0.014) but not for suspected SSA (5.9% vs. 5.3%, p=1), LST non-granular type (11.5% vs. 11.1%, p=1) and LST granular-type homogenous (33.3% vs. 23.9%, p=0.320).

Conclusion

Safety of CS-EMR is superior to HS-EMR for the removal of large, non-pedunculated colorectal polyps with an almost complete elimination of major complications. As general recurrence rate is higher after CS-EMR careful selection of the target lesion should be made. CS-EMR should be considered as new standard of care for suspected SSA, LST non-granular type with no macroscopic signs of malignancy and selected LST granular-type homogenous ≥20mm.

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; 49(03): 270-97.
² Hattem A, Shahidi N, Vosko S et al. Piecemeal cold snare polypectomy versus conventional endoscopic
mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods.
Gut 2021; 70(9): 1691-97.

Disclosure

Ingo Steinbrück: lecture fees and travel grants from Olympus and Falk Pharma
Helmut Messmann: none
Alanna Ebigbo: lecture fees from Olympus Medical, FujiFilm, Pentax, Ambu, Falk Pharma and Medtronic
Sandra Nagl: lecture fees from Falk Pharma, Pfizer and Sanofi
Armin Küllmer: lecture fees from Ovesco Endoscopy AG and Falk Pharma and consulting fees from KLS Martin Group, Tuttlingen, Germany
Sebastian Belle: none
Konstantinos Kouladouros: none
Alexander Meining: consultancy from Ovesco Endoscopy AG and Olympus Medical
Markus Brand: none
Jens Tischendorf: none
Teresa Koenen: none
Viktor Rempel: lecture fees and travel grants from Olympus and lecture fees from Microtec
Andreas Wannhoff: none
Carel Caca: none
Siegbert Faiss: lecture fees and consulting fees from Olympus and Ovesco Endoscopy AG
Matthias Mende: none
Oliver Pech: lecture fees from Medtronic, Aohua, AbbVie, Falk Pharma and Boston Scientific
Lukas Pfeifer: none
Oliver Möschler: lecture fees from Olympus Medical and FujiFilm
Franz-Ludwig Dumoulin: lecture fees and travel grants from Olympus
Martha Kirstein: none
Thomas von Hahn: lecture and consulting fees from Olympus
Hans-Dieter Allescher: none
Stefan Gölder: Lecture fees from Astra Zeneca, Falk Pharma, Pfizer and Apollo Endosurgery, funding of educational events from Advanz, Abbvie, B. Braun, Fresenius, Lilly, MSD, Janssen, Roche and Takeda
Martin Götz: consulting fees from Abbvie, Janssen and Galapagos, member of advisory board of Boehringer Ingelheim and Alexion, lecture fees from Abbvie, Takeda, Pentax, MSD and DGVS
Stephan Hollerbach: none
Felix Wiedbrauck: none
Björn Lewerenz: none
Arthur Schmidt: lecture fees from Falk Pharma and Olympus Medical
Hans-Peter Allgaier: lecture fees and travel grants from Olympus.

Introduction

Familial adenomatous polyposis (FAP) is a hereditary disorder that predisposes patients to colorectal cancer (CRC). Prophylactic colectomy has greatly reduced the risk of CRC. However, new associations between FAP and the risk of other cancers have subsequently emerged. In this study, we aimed to assess the risk of specific primary and secondary cancers among FAP patients in comparison with matched controls.

Aims & Methods

All known FAP patients up until April 2021 were identified in the nationwide Danish Polyposis Register and paired with four unique controls matched by birth year, sex, and zip code. Risk of overall cancers, specific cancer types, and risk of a second primary cancer were assessed and compared with controls.

Results

The analysis included 565 FAP patients and 1,890 controls. The overall risk of cancer was significantly higher for FAP patients than controls (hazard ratio (HR): 4.12, CI 95%, 3.28-5.17, p<0.001). The increased risk was mainly due to CRC (HR: 4.61, CI 95% 2.58-8.22, p<0.001), pancreatic cancer (HR: 6.45, CI 95% 2.02-20.64, p=0.002), and duodenal/small bowel cancer (HR: 14.49, CI 95% 1.76-119.47, p=0.013), while no significant difference was observed for gastric cancer (HR: 3.29, CI 95% 0.53-20.23, p=0.20). Furthermore, the risk of a second primary cancer was significantly higher for FAP patients (HR: 1.89, CI 95% 1.02-3.50, p=0.042). After 15 years, the point estimates for FAP patients and controls were 83.6 % vs. 94.8% being alive without cancer, 7.2% vs. 1.9% developing cancer, and 15.1% vs. 3.4% were deceased, respectively. When extending the period to 30 years, 60.7% vs. 81.1% were alive without cancer, 11.4% vs. 5.6% developed cancer, and 27.9% vs. 13.4% were deceased for FAP patients and controls, respectively. Between 1980 and 2020, the risk of cancer among FAP patients decreased by approximately 50%.

Conclusion

Analyzing national data for Danish polyposis patients and matched controls, we found that although the risk of developing cancer among FAP patients has been reduced by 50% over the last forty years, that risk is still significantly higher than for matched controls. Colorectal, pancreatic, and duodenal/small bowel cancer, as well as development of second primary cancers, are the main contributors to this increased risk. The risk of gastric cancer did not differ between FAP patients and controls. These findings should be included in future surveillance protocols and treatment guidelines for FAP patients.

References

Karstensen JG, Burisch J, Pommergaard HC, et al. Colorectal Cancer in Individuals With Familial Adenomatous Polyposis, Based on Analysis of the Danish Polyposis Registry. Clin Gastroenterol Hepatol 2019;17(11):2294-300 e1.
Monahan KJ, Bradshaw N, Dolwani S, et al. Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG). Gut 2020;69(3):411-44.
Karstensen JG, Bulow S, Burisch J, et al. Validation of the Endoscopic Part of the Spigelman Classification for Evaluating Duodenal Adenomatosis in Familial Adenomatous Polyposis: A Prospective Study of Interrater and Intrarater Reliability. Am J Gastroenterol 2022;117(2):343-45.
Monahan KJ, Bradshaw N, Dolwani S, et al. Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG). Gut 2020;69(3):411-44.

Disclosure

JGK is a consultant for SNIPR BIOME.