Impact of Annual Case Volume on Colorectal Endoscopic Submucosal Dissection Outcomes in a Large Prospective Cohort Study.

INTRODUCTION: The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort. METHODS: Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed. RESULTS: Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers. DISCUSSION: Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

Impact of linked color imaging on the proximal adenoma miss rate: a multicenter tandem randomized controlled trial (the COCORICO trial).

BACKGROUND: Missed lesions are common during standard colonoscopy and are correlated with post-colonoscopy colorectal cancer. Contrast-enhanced technologies have recently been developed to improve polyp detection. We aimed to evaluate the impact of linked color imaging (LCI) on the proximal adenoma miss rate in routine colonoscopy. METHODS: This national, multicenter, tandem, randomized trial compared the outcomes of colonoscopy with white-light imaging (WLI) versus LCI for polyp detection in the right colon. Two consecutive examinations of the right colon (upstream of the hepatic flexure) were made with WLI and LCI by the same operator. First-pass examination by WLI or LCI was randomized 1:1 after cecal intubation. According to statistical calculations, 10 endoscopy units had to include approximately 700 patients. The primary outcome was proximal adenoma miss rate. Secondary outcomes were the proximal miss rates for sessile serrated lesions (SSL), advanced adenomas, and polyps. RESULTS: 764 patients were included from 1 January 2020 to 22 December 2022, and 686 patients were randomized (345 WLI first vs. 341 LCI first). Both groups were comparable in terms of demographics and indications. The proximal adenoma miss rate was not significantly higher in the WLI-first group (36.7%) vs. the LCI-first group (31.8%) (estimated mean absolute difference: 4.9% [95%CI -5.2% to 15.0%], P = 0.34). There was also no significant difference in miss rates for SSLs, advanced adenomas, and polyps in the proximal colon. CONCLUSIONS: In contrast to previous data, this study does not support the benefit of LCI to the proximal adenoma miss rate in routine colonoscopy.

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024.

1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Is laparoscopic approach as treatment of large gastric GIST acceptable?

AIM: Laparoscopic surgery is widely used for small gastric gastrointestinal stromal tumors (GISTs) (≤ 5 cm) but remains a controversial approach for larger gastric GISTs (> 5 cm). This study aims to compare short- and long-term outcomes of laparoscopic resection in comparison with open resection for gastric GISTs measuring over 5 cm. METHOD: All patients receiving surgery for gastric GIST > 5 cm between 2000 and 2021 in a single tertiary hospital were included. Data were collected from prospectively maintained records. Kaplan-Meier method and log rank test were used to compare survival outcomes. RESULTS: Among 108 included patients, 59 patients had minimally invasive (MI) surgery (54.6%) whereas 49 patients had open surgery (46.4%). The rate of overall postoperative morbidity was 14.8% and the median length was significantly shorter in the MI group [4 (range 2-30) vs. 7 (range 4-33) days; P = 0.007]. The overall R0 resection rate was 98.2% and the rate of tumor rupture was 13%, not different between the two groups. Recurrence occurred in 24% of the whole population without any difference between groups (20.3% vs. 28.7%, p = 0.31). Minimally invasive surgery was not found as a negative prognostic disease-free survival factor. CONCLUSION: Laparoscopic surgery could be a safe and feasible alternative to open surgery in large gastric GIST, bringing the benefits of minimally invasive surgery without compromising oncologic results.

Management after local excision of small rectal cancers. Indications for completion total mesorectal excision and possible alternatives.

The treatment of superficial rectal cancers (local excision, or proctectomy with total mesorectal excision (TME) remains controversial. Endoscopy and endorectal ultrasonography are essential for the precise initial definition of these small cancers. During endoscopy, the depth of the lesion can be estimated using virtual chromoendoscopy with magnification, thereby aiding the assessment of the possibilities of local excision. Current international recommendations indicate completion proctectomy after wide local excision for cases where the pathologic examination reveals poorly-differentiated lesions, lymphovascular invasion, grade 2 or 3 tumor budding, and incomplete resection. But debate persists regarding whether the depth of submucosal invasion can accurately predict the risk of lymph node spread. Recent data from the literature suggest that the depth of submucosal invasion should no longer, by itself, be an indication for additional oncological surgery. Adjuvant radio-chemotherapy could be an alternative to completion proctectomy in patients with pT1 rectal cancer and unfavorable histopathological criteria. A Dutch randomized controlled trial is underway to validate this strategy.

Artificial intelligence for characterization of colorectal polyps: Prospective multicenter study.

Background and study aims Optical diagnosis poses challenges to implementation of "resect and discard" strategies. This study aimed to assess the feasibility and performance of a new commercially available system for colorectal polyps. Patients and methods Nine expert endoscopists in three centers performed colonoscopies using artificial intelligence-equipped colonoscopes (CAD EYE, Fujifilm). Histology and predictions were compared, with hyperplastic polyps and sessile serrated lesions grouped for analysis. Results Overall, 253 polyps in 119 patients were documented (n=152 adenomas, n=78 hyperplastic polyps, n=23 sessile serrated lesions). CAD EYE detected polyps before endoscopists in 81 of 253 cases (32%). The mean polyp size was 5.5 mm (SD 0.6 mm). Polyp morphology was Paris Ip (4 %), Is (28 %), IIa (60 %), and IIb (8 %). CAD EYE achieved a sensitivity of 80%, specificity of 83%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 72%. Expert endoscopists had a sensitivity of 88%, specificity of 83%, PPV of 96%, and NPV of 72%. Diagnostic accuracy was similar between CAD EYE (81%) and endoscopists (86%). However, sensitivity was greater with endoscopists as compared with CAD EYE ( P <0.05). CAD EYE classified sessile serrated lesions as hyperplasia in 22 of 23 cases, and endoscopists correctly classified 16 of 23 cases. Conclusions The CAD EYE system shows promise for detecting and characterizing colorectal polyps. Larger studies are needed, however, to confirm these findings.

Guessing the future of endoscopic drainage of walled-off necrosis

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A comprehensive systematic review and meta-analysis of risk factors for rebleeding following device-assisted enteroscopy therapy of small-bowel vascular lesions

INTRODUCTION: the aim of this study was to determine the risk factors for rebleeding following device-assisted enteroscopy therapy of small bowel vascular lesions. METHODS: this is a systematic review and meta-analysis. A literature search was performed from January 2003 to October 2019. All studies reporting on at least one risk factor for bleeding recurrence after endoscopic therapy of small bowel vascular lesions were included. A meta-analysis of those risk factors reported in at least three studies was performed to assess their association with rebleeding. The OR and 95 % CI were used for binary outcome data. Heterogeneity analysis was performed using the Tau and I2 index. If I2 > 20 %, potential sources of heterogeneity were identified by sensitivity analyses and a random-effect model was used. RESULTS: the search identified a total of 572 articles and 35 full-text records were assessed for eligibility after screening. Finally, eight studies that included 548 patients were selected. The overall median rebleeding rate was 38.5 % (range: 10.9-53.3 %) with a median follow-up of 24.5 months. Female sex (OR: 1.96, 95 % CI: 1.14-3.37, p = 0.01, I2 = 0 %), Osler-Weber syndrome (OR: 4.35, 95 % CI: 1.22-15.45, p = 0.02, I2 = 0 %) and cardiac disease (OR: 1.89, 95 % CI: 1.12-2.97, p = 0.005, I2: 0 %) were associated with rebleeding. According to the sensitivity analysis, overt bleeding (OR: 2.13, 95 % CI: 1.22-3.70, p = 0.007, I2 = 0 %), multiple lesions (OR: 4.57, 95 % CI: 2.04-10.22, p < 0.001, I2 = 0 %) and liver cirrhosis (OR: 2.61, 95 % CI: 1.11-6.13, p = 0.03, I2 = 0 %) were also predictors for rebleeding. CONCLUSIONS: patient characteristics and comorbidities should be considered for follow-up patient management after effective device-assisted endoscopic therapy, as they can predict rebleeding

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