The aim of this study was to clarify whether dental floss clip (DFC) traction improves the technical outcomes of endoscopic submucosal dissection (ESD).
A superiority, randomized control trial was ...conducted at 14 institutions across Japan. Patients with single gastric neoplasm meeting the indications of the Japanese guidelines for gastric treatment were enrolled and assigned to receive conventional ESD or DFC traction-assisted ESD (DFC-ESD). Randomization was performed according to a computer-generated random sequence with stratification by institution, tumor location, tumor size, and operator experience. The primary endpoint was ESD procedure time, defined as the time from the start of the submucosal injection to the end of the tumor removal procedure.
Between July 2015 and September 2016, 640 patients underwent randomization. Of these, 316 patients who underwent conventional ESD and 319 patients who underwent DFC-ESD were included in our analysis. The mean ESD procedure time was 60.7 and 58.1 minutes for conventional ESD and DFC-ESD, respectively (P = .45). Perforation was less frequent in the DFC-ESD group (2.2% vs .3%, P = .04). For lesions located in the greater curvature of the upper or middle stomach, the mean procedure time was significantly shorter in the DFC-ESD group (104.1 vs 57.2 minutes, P = .01).
Our findings suggest that DFC-ESD does not result in shorter procedure time in the overall patient population, but it can reduce the risk of perforation. When selectively applied to lesions located in the greater curvature of the upper or middle stomach, DFC-ESD provides a remarkable reduction in procedure time.
We herein report a case of intraperitoneal abscess as a postoperative complication of gastric endoscopic submucosal dissection (ESD). A 70-year-old man who underwent ESD for early gastric cancer ...sought consultation for abdominal pain on postoperative day 28. Abdominal computed tomography revealed intraperitoneal abscess rupture. He underwent image-guided laparoscopic irrigation. His postoperative course was favorable, and he was discharged after 27 days. Intraoperatively, a white plaque adhering to the gastric wall was surrounded by a large pus volume and suspected to be ESD-associated. We present this case with a literature review of the association between intraperitoneal abscess and ESD.
The indications for endoscopic submucosal dissection (ESD) in superficial nonampullary duodenal epithelial tumors (SNADETs) remain controversial because the procedure is technically challenging. ...Moreover, the effectiveness of clip-and-thread traction-assisted ESD (TA-ESD) for SNADETs has not been assessed. The aim of the current study was to compare the effectiveness of duodenal TA-ESD and conventional ESD for SNADETs.
SNADETs treated with conventional ESD or TA-ESD between April 2017 and March 2021 at Saitama Medical University International Medical Center were evaluated retrospectively.
There were 49 cases of conventional ESD and 32 cases of TA-ESD for SNADETs. Using a propensity score–matched design, we selected 26 pairs of cases with conventional ESD and TA-ESD. In the unmatched cohort, patients treated with TA-ESD were characterized by a higher R0 (no tumor identified at the lateral or vertical margins) resection rate (P = .004), more frequent poor submucosal lifting because of fibrosis (P = .014), and shorter follow-up period (P = .0004) than patients treated with conventional ESD. In the propensity score–matched pairs, patients treated with TA-ESD were characterized by a higher rate of R0 resection (P = .021) and a shorter follow-up period (P = .0061). The findings regarding R0 resection rates were confirmed by multivariate logistic regression models, which found a higher odds ratio (OR) for R0 resection in patients who underwent TA-ESD than in patients who underwent conventional ESD both in the unmatched cohort (OR, 17.0; 95% confidence interval, 1.6-178.8; P = .018) and in the propensity score–matched pairs (OR, 26.7; 95% confidence interval, 1.5-460.2; P = .024).
Our findings suggest TA-ESD may increase the rate of R0 resection in patients with SNADETs in comparison with conventional ESD.
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Objectives
This study aimed to evaluate the trainees’ practice and learning curve in short‐type single‐balloon enteroscopy (short SBE)‐assisted endoscopic retrograde cholangiopancreatography (ERCP) ...for patients with surgically altered anatomy (SAA) and determine how to train these trainees.
Methods
The data of short SBE‐assisted ERCP procedures between September 2011 and June 2021 were analyzed.
Results
Three trainees and 180 cases were included in the analysis. Each trainee performed 60 cases between April 2016 and June 2021. The trainees' completion rate was 73.9% (95% confidence interval CI, 66.8‐80.1%). Adverse events occurred in 5.0% of cases (95% CI, 2.3‐9.3%). The trainee who experienced colonoscopy and ERCP the most achieved better outcomes of enteroscopy success (reaching the target site) and trainee’s completion rates than those of the others (P = .03 and .02, respectively). The learning curve for trainee’s completion showed a significant improvement after 60 cases (P = .001). Multiple logistic regression analysis indicated that Roux‐en‐Y reconstruction was the factor affecting trainees’ completion failure.
Conclusions
Short SBE‐assisted ERCP trainees has a substantial learning curve. If trainees do not have much experience with colonoscopy and ERCP procedures, it may be beneficial for them to start performing short SBE‐assisted ERCP procedures on non‐Roux‐en‐Y reconstruction cases.
Evaluation of trainees' practice and learning curves in short‐type single‐balloon enteroscopy‐assisted ERCP for patients with surgically altered anatomy revealed that trainees' successful completion rates significantly improved after 60 cases. Tanisaka et al. conclude that short‐type single‐balloon enteroscopy‐assisted ERCP poses a substantial learning curve for trainees.
Abstract
Colorectal endoscopic submucosal dissection (ESD) is a difficult procedure, and its introduction to trainees has been debated. Although the criteria for performing colorectal ESD vary among ...institutions, it is often allowed after gaining experience performing surgeries in animals and upper gastrointestinal ESD. This pilot study aimed to compare the treatment outcomes of ESD performed by trainees using the multi-loop traction device (MLTD group) and those of conventional ESD performed by experts (control group). It also aimed to determine whether the MLTD can be used to safely introduce colorectal ESD to trainees. We included 26 colorectal ESD patients (13 in the MLTD group and 13 in the control group) treated at our hospital from October to December 2021. There were no significant differences in the procedure time (50 min vs. 30 min), dissection speed (19.9 mm
2
/min vs. 28.7 mm
2
/min), and intraoperative perforation (0% vs. 0%) of the two groups. Furthermore, the rate of ESD self-completion in the MLTD group was 100%. Therefore, the use of the MLTD allowed the safe introduction of colorectal ESD, even among endoscopists with no experience performing colorectal ESD. Consequently, the use of the MLTD may replace animal and upper gastrointestinal ESD when introducing colorectal ESD to trainees.
Background Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer; however, it is not widely used in the colorectum because of its technical ...difficulty. Objective To determine the feasibility of using ESD for treating large superficial colorectal tumors and to evaluate the clinical outcome. Design and Setting Case series conducted at the National Cancer Center Hospital in Tokyo. Patients A total of 198 consecutive patients were treated for 200 lesions. Interventions Procedures were performed, before July 2004, by using a monopolar needle knife or an insulation-tipped knife (IT knife). After July 2004, the procedures were performed by using a bipolar needle knife or an IT knife. After injection of glycerol and sodium hyaluronate acid into the submucosal (sm) layer, a circumferential incision was made and sm dissection was performed endoscopically. Main Outcome Measurements The en bloc resection rate was 84% and the curative resection rate was 83%. Results Among the 200 ESDs, 51 involved tubular adenomas, 99 intramucosal cancers, 22 minute sm cancers, and 28 sm deep cancers. The median operation time was 90 minutes, and the mean size of resected specimens was 38 mm (range, 20-150 mm). Perforations occurred in 10 cases (5%) and postoperative bleeding in 4 cases (2%), but only 1 perforation case needed emergency surgery, because endoscopic clipping was ineffective. Limitations No long-term outcome data yet. Conclusions ESD is a feasible technique for treating large superficial colorectal tumors, because it provides a higher en bloc resection rate and is less invasive than surgical resection.
Highlight
Bile duct stone extraction is sometimes difficult in patients with surgically altered anatomy. Tanisaka and colleagues present a video case report demonstrating the usefulness of a novel ...retrieval basket with a unique helical shape, which facilitates the extraction of difficult bile duct stones, even in patients with surgically altered anatomy.
Background: We developed a new endoscopic resection method that combines endoscopic mucosal resection (EMR) with an over-the-scope clip (OTSC), termed EMR-O. In this study, we aimed to evaluate the ...short-term outcomes of EMR-O for colorectal tumors. Method: In total, 9 consecutive patients who underwent EMR-O from September 2017 and October 2022 were retrospectively enrolled. Patients' characteristics and treatment outcomes were evaluated. Result: The En bloc and R0 resection rates were 100% and 89%. The median resected specimen size was 16 (10-27) mm, with a median resected tumor size was 8 (5-17) mm. The median procedure time was 10 (7-15) min. There were no intraoperative or delayed perforation and postoperative bleeding. Discussion: Although EMR-O has limitations in target lesion size, it has the advantages of a short procedure time and the prevention of perforation.
To evaluate the outcomes and factors influencing colorectal endoscopic submucosal dissection (ESD) with a long procedure time.
In this single-center, retrospective study, we included 1,100 patients ...with 1,199 lesions who underwent colorectal ESD between April 2016 and December 2020. ESD was performed using an advanced system knife for lesions >20 mm. An S-O clip was used as the traction device. The long-time group (LP; procedure time >120 min) and normal-time group (NP; procedure time <120 min) were compared.
The procedure times were 166.86 and 44.72 min in the LP and NP groups, respectively. The completion rate was higher in the NP group (96.5% vs. 83.5%, p = .001); the completed lesions were resected en bloc. Multivariate analysis revealed 18.8% and 7.8% of submucosal fibrosis in the LP and NP groups, respectively (odds ratio OR = 2.410, p = .026). Compared to the NP group, the LP group presented larger maximum lesion sizes and higher rates of R1 resection, and traction device use. Time to introduction of traction device use was longer in the LP than in the NP group (126.05 vs. 21.72 min; p < .001). Fibrosis tends to occur cecal lesions (OR 2.436, p = .011) and laterally spreading tumor-non-granular-pseudo-depressed (LST-NG-PD) (OR 2.6181, p = .001).
Lesion size and fibrosis were factors associated with a long procedure time in colonic ESD. For fibrotic lesions (LST-NG-PD and cecal lesions), it is necessary to consider early use of traction devices and advisable to plan a strategy for the use of traction devices.
Objectives
Understanding the exact morphology of the bile duct opening is important for determining the success of bile duct cannulation. Texture and color enhancement imaging (TXI) has been reported ...to enhance slight changes in color tone and structure that are difficult to see with white light imaging. This study investigated whether TXI mode1 could improve papillary recognition by trainees inexperienced in endoscopic retrograde cholangiopancreatography.
Methods
We included 31 patients with naive papilla of Vater at a single institution in the study. Trainee endoscopists (n = 4) evaluated and identified the papilla according to the Inomata classification using white light imaging and TXI. The degree of agreement with the evaluation of supervising physicians (n = 4) was examined using the McNemar test.
Results
In the trainee group, the kappa coefficient agreements were κ = 0.346 and κ = 0.754 for white light imaging and TXI, respectively. When further evaluated, the separate and septal types of papilla groups showed an increased concordance rate in one of the four trainees (76.67%–96.67%, p = 0.031, respectively). Moreover, comparison for two‐group evaluation showed an increased kappa coefficient in two of four trainees (0.34–0.92, p = 0.010, 0.45–0.92, p = 0.024).
Conclusions
Observation of the duodenal papilla using TXI improved papillary differentiation and suggested the potential of TXI as a clinical tool. Further study of this method is necessary; it is expected to help reduce cannulation time and the incidence of pancreatitis.
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