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BACKGROUND: Endoscopic resection of adenomas prevents colorectal cancer, but the optimal technique for larger lesions is controversial. Piecemeal endoscopic mucosal resection (EMR) has a low adverse event (AE) rate but a variable recurrence rate necessitating early follow-up. Endoscopic submucosal dissection (ESD) can reduce recurrence but may increase AEs. OBJECTIVE: To compare ESD and EMR for large colonic adenomas. DESIGN: Participant-masked, parallel-group, superiority, randomized controlled trial. (ClinicalTrials.gov: NCT03962868). SETTING: Multicenter study involving 6 French referral centers from November 2019 to February 2021. PARTICIPANTS: Patients with large (≥25 mm) benign colonic lesions referred for resection. INTERVENTION: The patients were randomly assigned by computer 1:1 (stratification by lesion location and center) to ESD or EMR. MEASUREMENTS: The primary end point was 6-month local recurrence (neoplastic tissue on endoscopic assessment and scar biopsy). The secondary end points were technical failure, en bloc R0 resection, and cumulative AEs. RESULTS: In total, 360 patients were randomly assigned to ESD (n = 178) or EMR (n = 182). In the primary analysis set (n = 318 lesions in 318 patients), recurrence occurred after 1 of 161 ESDs (0.6%) and 8 of 157 EMRs (5.1%) (relative risk, 0.12 [95% CI, 0.01 to 0.96]). No recurrence occurred in R0-resected cases (90%) after ESD. The AEs occurred more often after ESD than EMR (35.6% vs. 24.5%, respectively; relative risk, 1.4 [CI, 1.0 to 2.0]). LIMITATION: Procedures were performed under general anesthesia during hospitalization in accordance with the French health system. CONCLUSION: Compared with EMR, ESD reduces the 6-month recurrence rate, obviating the need for systematic early follow-up colonoscopy at the cost of more AEs. PRIMARY FUNDING SOURCE: French Ministry of Health.
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Adenoma , Neoplasias do Colo , Neoplasias Colorretais , Humanos , Neoplasias do Colo/cirurgia , Neoplasias do Colo/patologia , Colonoscopia/efeitos adversos , Colonoscopia/métodos , Biópsia , Adenoma/cirurgia , Adenoma/patologia , Resultado do Tratamento , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Recidiva Local de Neoplasia , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Estudos RetrospectivosRESUMO
INTRODUCTION: The environmental impact of endoscopy is a topic of growing interest. This study aimed to compare the carbon footprint of performing an esogastroduodenoscopy (EGD) with a reusable (RU) or with a single-use (SU) disposable gastroscope. METHODS: SU (Ambu aScope Gastro) and RU gastroscopes (Olympus, H190) were evaluated using life cycle assessment methodology (ISO 14040) including the manufacture, distribution, usage, reprocessing and disposal of the endoscope. Data were obtained from Edouard Herriot Hospital (Lyon, France) from April 2023 to February 2024. Primary outcome was the carbon footprint (measured in Kg CO2 equivalent) for both gastroscopes per examination. Secondary outcomes included other environmental impacts. A sensitivity analysis was performed to examine the impact of varying scenarios. RESULTS: Carbon footprint of SU and RU gastroscopes were 10.9 kg CO2 eq and 4.7 kg CO2 eq, respectively. The difference in carbon footprint equals one conventional car drive of 28 km or 6 days of CO2 emission of an average European household. Based on environmentally-extended input-output life cycle assessment, the estimated per-use carbon footprint of the endoscope stack and washer was 0.18 kg CO2 eq in SU strategy versus 0.56 kg CO2 eq in RU strategy. According to secondary outcomes, fossil eq depletion was 130 MJ (SU) and 60.9 MJ (RU) and water depletion for 6.2 m3 (SU) and 9.5 m3 (RU), respectively. CONCLUSION: For one examination, SU gastroscope have a 2.5 times higher carbon footprint than RU ones. These data will help with the logistics and planning of an endoscopic service in relation to other economic and environmental factors.
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INTRODUCTION: When initial resection of rectal neuroendocrine tumors (r-NETs) is not R0, persistence of local residue could lead to disease recurrence. This study aimed to evaluate the interest of systematic resection of non-R0 r-NET scars. METHODS: Retrospective analysis of all the consecutive endoscopic revisions and resections of the scar after non-R0 resections of r-NETs. RESULTS: A total of 100 patients were included. Salvage endoscopic procedure using endoscopic submucosal dissection or endoscopic full-thickness resection showed an R0 rate of near 100%. Residual r-NET was found in 43% of cases. DISCUSSION: In case of non-R0 resected r-NET, systematic scar resection by endoscopic full-thickness resection or endoscopic submucosal dissection seems necessary.
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Ressecção Endoscópica de Mucosa , Tumores Neuroendócrinos , Neoplasias Retais , Humanos , Tumores Neuroendócrinos/cirurgia , Cicatriz/etiologia , Cicatriz/patologia , Estudos Retrospectivos , Resultado do Tratamento , Recidiva Local de Neoplasia/cirurgia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Ressecção Endoscópica de Mucosa/métodosRESUMO
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.
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BACKGROUND AND AIMS: Traction has become the reference strategy for colorectal endoscopic submucosal dissection (ESD). One of its major limitations is that the force of traction decreases as dissection progresses. The ATRACT traction device (ATRACT Device and Co, Lyon, France) uses a pulley system to increase traction during the procedure, making it easier and faster. A retrospective study of 54 cases showed interesting results in terms of efficacy and safety throughout the digestive tract. We sought to confirm these initial results with a prospective study of resections of colorectal lesions. METHODS: In this prospective multicenter study, 5 experienced operators from 3 different centers each performed 10 procedures using the ATRACT device consecutively for all conventional colorectal ESDs measuring between 4 and 10 cm in conventional locations (no recurrent lesions, appendicular, of the ileocecal valve, in contact with the pectinate line, or measuring more than two-thirds of the circumference). RESULTS: Between November 2022 and April 2023, 50 ESDs were performed in 49 patients. On average, the main diameter of the lesions was 66.6 mm, with a surface area of 3066 mm2. The mean operating time was 55.2 minutes, resulting in a mean resection speed of 61.4 mm2/min. En bloc and R0 resection rates were 100% and 98%, respectively. Resections were curative in 94% of cases. Four (8%) perforations occurred, all of which were closed endoscopically without the need for surgery. One (2%) case of delayed hemorrhage was noted. To date, this is the series with the highest resection speeds in the literature for colorectal ESD. For comparison, previous studies reported a speed of 23.5 mm2/min using the "pocket" strategy and a speed of 39.1 mm2/min using the double-clip traction technique. These results need to be confirmed in larger studies and in nonexpert centers. CONCLUSIONS: This prospective evaluation confirms the efficacy and safety of the adaptive traction strategy with the ATRACT device for colorectal ESD with high resection speed.
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Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Duração da Cirurgia , Tração , Humanos , Ressecção Endoscópica de Mucosa/métodos , Ressecção Endoscópica de Mucosa/instrumentação , Estudos Prospectivos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Neoplasias Colorretais/cirurgia , Tração/métodos , Tração/instrumentação , Idoso de 80 Anos ou mais , Colonoscopia/métodos , Mucosa Intestinal/cirurgia , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgiaRESUMO
BACKGROUND AND AIMS: Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries. METHODS: We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events. RESULTS: A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%. CONCLUSIONS: In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures.
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Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Carcinoma de Células Escamosas do Esôfago , Humanos , Carcinoma de Células Escamosas do Esôfago/cirurgia , Neoplasias Esofágicas/patologia , Ressecção Endoscópica de Mucosa/métodos , Esofagoscopia/métodos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
BACKGROUND : Good submucosal exposure is key to successful endoscopic submucosal dissection (ESD) and can be achieved with various traction devices. Nevertheless, these devices have a fixed traction force that tends to decrease as the dissection progresses. In contrast, the ATRACT adaptive traction device increases traction during the procedure. METHODS : In this retrospective analysis of prospectively collected data (from a French database), we analyzed ESD procedures performed with the ATRACT device between April 2022 and October 2022. The device was used consecutively whenever possible. We collected details of lesion characteristics, procedural data, histologic outcomes, and clinical consequences for the patient. RESULTS : 54 resections performed in 52 patients by two experienced operators (46 procedures) and six novices (eight procedures) were analyzed. The ATRACT devices used were the ATRACT-2 (nâ=â21), the ATRACT 2â+â2 (nâ=â30), and the ATRACT-4 (nâ=â3). Four adverse events were observed: one perforation (1.9â%), which was closed endoscopically, and three delayed bleeding events (5.5â%). The R0 rate was 93â%, resulting in curative resection in 91â% of cases. CONCLUSION: ESD using the ATRACT device is safe and effective in the colon and rectum, but can also be used to assist with procedures in the upper gastrointestinal tract. It may be particularly useful in difficult locations.
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Ressecção Endoscópica de Mucosa , Humanos , Ressecção Endoscópica de Mucosa/métodos , Estudos Retrospectivos , Reto , Dissecação/efeitos adversos , Dissecação/métodos , Tração , Resultado do TratamentoRESUMO
INTRODUCTION: Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI). METHODS: This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life. RESULTS: 40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant). CONCLUSION: G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.
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Toxinas Botulínicas , Gastroparesia , Piloromiotomia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Toxinas Botulínicas/administração & dosagem , Toxinas Botulínicas/efeitos adversos , Esvaziamento Gástrico/efeitos dos fármacos , Gastroparesia/tratamento farmacológico , Gastroparesia/etiologia , Gastroparesia/cirurgia , Gastroscopia , Injeções , Piloromiotomia/métodos , Piloromiotomia/efeitos adversos , Piloro/cirurgia , Qualidade de Vida , Cintilografia , Resultado do TratamentoRESUMO
BACKGROUND: The ileocecal valve (ICV) is considered to be one of the most difficult locations for endoscopic submucosal dissection (ESD). The objective of this study was to evaluate the efficacy and safety of traction-assisted ESD in this situation. METHODS: All patients who underwent traction-assisted ESD for an ICV lesion at three centers were identified from a prospective ESD database. En bloc and R0 rates were evaluated. Factors associated with non-R0 resection were explored. RESULTS: 106 patients with an ICV lesion were included. The median lesion size was 50 mm (interquartile range 38-60) and 58.5% (62/106) invaded the terminal ileum. The en bloc and R0 resection rates were 94.3% and 76.4%, respectively. Factors associated with non-R0 resection were lesions covering ≥75% of the ICV (odds ratio [OR] 0.21. 95%CI 0.06-0.76; P=0.02), and involving the anal lip (OR 0.36, 95%CI 0.13-0.99; P=0.04) or more than two sites on the ICV (OR 0.27, 95%CI 0.07-0.99; P=0.03). CONCLUSION: Traction-assisted ESD for treatment of ICV lesions was a safe and feasible option. Large lesions and anal lip involvement appeared to be factors predictive of difficulty.
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INTRODUCTION: The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), is a topic of growing attention and concern. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO2) generated by an SBCE procedure. METHODS: Life cycle assessment methodology (ISO 14040) was used to evaluate three brands of SBCE device and included emissions generated by patient travel, bowel preparation, capsule examination, and video recording. A survey of 87 physicians and 120 patients was conducted to obtain data on travel, activities undertaken during the procedure, and awareness of environmental impacts. RESULTS: The capsule itself (4âg) accounted forâ<â6â% of the total product weight. Packaging (43-119âg) accounted for 9â%-97â% of total weight, and included deactivation magnets (5âg [4â%-6â%]) and paper instructions (11-50âg [up to 40â%]). A full SBCE procedure generated approximately 20âkgCO2, with 0.04âkgCO2 (0.2â%) attributable to the capsule itself and 18âkgCO2 (94.7â%) generated by patient travel. Capsule retrieval using a dedicated device would add 0.98âkgCO2 to the carbon footprint. Capsule deconstruction revealed materials (e.âg. neodymium) that are prohibited from environmental disposal; 76â% of patients were not aware of the illegal nature of capsule disposal via wastewater, and 63â% would have been willing to retrieve it. The carbon impact of data storage and capsule reading was negligible. CONCLUSION: The carbon footprint of SBCE is mainly determined by patient travel. The capsule device itself has a relatively low carbon footprint. Given that disposal of capsule components via wastewater is illegal, retrieval of the capsule is necessary but would likely be associated with an increase in device-related emissions.
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BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is challenging for appendicular lesions. We report the outcomes of ESD in this context. METHODS: We collected data of ESD procedures for appendiceal neoplasia in a multicenter prospective registry. Main study endpoints were R0, en-bloc, and curative resection rates and adverse event rate. RESULTS: One hundred twelve patients were included, 47 (42%) with previous appendectomy. Fifty-six (50%) were Toyonaga type 3 lesions (15 [13.4%] postappendectomy). En-bloc and R0 resection rates were 86.6% and 80.4%, respectively, with no significant difference associated with different grades of appendiceal invasion (P = .9 and P = .4, respectively) or previous appendectomy (P = .3 for both). The curative resection rate was 78.6%. Additional surgery was performed in 16 cases (14.3%), including 10 (62.5%) Toyonaga type 3 lesions (P = .04). This included the treatment of 5 cases (4.5%) of delayed perforation and 1 acute appendicitis. CONCLUSIONS: ESD for appendicular lesions is a potentially safer and effective alternative to surgery for a significant proportion of patients.
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Apêndice , Ressecção Endoscópica de Mucosa , Humanos , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Estudos Retrospectivos , Apendicectomia , Resultado do TratamentoRESUMO
BACKGROUND: Endoscopic submucosal dissection (ESD) is potentially a curative treatment for T1 colorectal cancer under certain conditions. The aim of this study was to evaluate the feasibility and effectiveness of ESD for lesions with a suspicion of focal deep invasion. METHODS: In this retrospective multicenter study, consecutive patients with colorectal neoplasia displaying a focal (< 15âmm) deep invasive pattern (FDIP) that were treated by ESD were included. We excluded ulcerated lesions (Paris III), lesions with distant metastasis, and clearly advanced tumors (tumoral strictures). RESULTS: 124 patients benefited from 126 diagnostic dissection attempts for FDIP lesions. Dissection was feasible in 120/126 attempts (95.2â%) and, where possible, the en bloc and R0 resection rates were 95.8â% (115/120) and 76.7â% (92/120), respectively. Thirty-three resections (26.2â%) were for very low risk tumors, so considered curative, and 38 (30.2â%) were for low risk lesions. Noncurative R0 resections were for lesions with lymphatic or vascular invasion (LVI; nâ=â8), or significant budding (nâ=â9), and LVIâ+âbudding combination (nâ=â4). CONCLUSION: ESD is feasible and safe for colorectal lesions with an FDIPâ≤â15âmm. It was curative in 26.6â% of patients and could be a valid option for a further 30.6â% of patients with low risk T1 cancers, especially for frail patients with co-morbidities.
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Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Humanos , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Ressecção Endoscópica de Mucosa/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Estudos de ViabilidadeRESUMO
INTRODUCTION : Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different management techniques are feasible including endoscopic full-thickness resection using the full-thickness resection device (FTRD) system and endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of these two techniques for the treatment of such lesions. METHODS : All consecutive patients with RCN treated either using the FTRD or by ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate, defined as an en bloc resection with histologically tumor-free lateral and deep margins. RESULTS : 275 patients (median age 70 years; 160 men) who underwent 177 ESD and 98 FTRD procedures for RCN were included. R0 resection was achieved in 83.3â% and 77.6â% for ESD and FTRD, respectively (Pâ=â0.25). Lesions treated by ESD were however larger than those treated by FTRD (Pâ<â0.001). The R0 rates for lesions of 20-30âmm were 83.9â% and 57.1â% in the ESD and FTRD groups, respectively, and for lesions of 30-40âmm were 93.6â% and 33.3â%, respectively. On multivariable analysis, ESD procedures were associated with statistically higher en bloc and R0 resection rates after adjustment for lesion size (Pâ=â0.02 and Pâ<â0.001, respectively). The adverse event rate was higher in the ESD group (16.3â% vs. 5.1â%), mostly owing to intraoperative perforations. CONCLUSION: ESD is effective in achieving R0 resection for RCN whatever the size and location of the lesions. When residual lesions are smaller than 20âmm, the FTRD is an effective alternative.
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Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Masculino , Humanos , Idoso , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Estudos Retrospectivos , Estudos de Coortes , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Endoscopia , Resultado do TratamentoRESUMO
BACKGROUND: Esophageal endoscopic submucosal dissection (ESD) is the gold standard for the treatment of precancerous lesions or superficial esophageal cancers. This procedure is currently performed by expert endoscopists only, and poorly standardized. We aimed to assess the technical results and outcomes of a "tunnel + clip" strategy for esophageal ESD procedures performed by less experienced operators for the treatment of superficial neoplasms. METHODS: All consecutive esophageal ESDs performed with the "tunnel + clip" technique for patients with early esophageal cancer in 3 centers were enrolled. Procedural characteristics, clinical outcomes, and complications were recorded. RESULTS: Among 195 esophageal ESD procedures performed, early adenocarcinomas or high-grade dysplasia complicating Barrett's esophagus were predominant (132/195, 67.7%) compared with early squamous cell carcinomas (63/195, 32.3%). The en bloc, R0 and curative resection rates were 100% (195/195), 78.5% (153/195) and 67.2% (131/195), respectively. The mean rate of ESD was 29.7 mm2/min. One (0.5%) perprocedural perforation and 7 (3.6%) postprocedural bleedings occurred, all managed endoscopically. No delayed perforation occurred. Overall, 31 patients (31/195; 15.9%) of patients developed stenosis. CONCLUSIONS: The "tunnel + clip" strategy is safe, and allows to achieve high en bloc, R0 and curative resection rates. This standardized procedure could be used by physicians with little experience and might help spreading esophageal ESD in Western countries.
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Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Humanos , Ressecção Endoscópica de Mucosa/métodos , Tração , Esofagoscopia/métodos , Resultado do Tratamento , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/patologia , Instrumentos Cirúrgicos , Estudos RetrospectivosRESUMO
OBJECTIVE: Endoscopic submucosal dissection (ESD) in a curative intent for submucosa-invasive early (T1) colorectal cancers (T1-CRCs) often leads to subsequent surgical resection in case of histologic parameters indicating higher risk of nodal involvement. In some cases, however, the expected benefit may be offset by the surgical risks, suggesting a more conservative approach. DESIGN: Retrospective analysis of consecutive patients with T1-CRC who underwent ESD at 13 centres ending inclusion in 2019 (n=3373). Cases with high risk of nodal involvement (non-curative ESD: G3, submucosal invasion>1000 µm, lymphovascular involvement, budding or incomplete resection/R1) were analysed if follow-up data (endoscopy/imaging) were available, regardless of the postendoscopic management (follow-up vs surgery) selected by the multidisciplinary teams in these institutions. Comorbidities were classified according to Charlson Comorbidity Index (CCI). Outcomes were disease recurrence, death and disease-related death rates in the two groups. Rate of residual disease (RD) at both the previous resection site and regional lymph nodes was assessed in the surgical cases as well as from follow-up in the follow-up group. RESULTS: Of 604 patients treated by colorectal ESD for submucosally invasive cancer, 207 non-curative resections (34.3%) were included (138 male; mean age 67.6±10.9 years); in 65.2% of cases, no complete resection was achieved (R1). Of the 207 cases, 60.9% (n=126; median CCI: 3; IQR: 2-4) underwent surgical treatment with RD in 19.8% (25/126), while 39.1% (n=81, median CCI: 5; IQR: 4-6) were followed up by endoscopy in all cases. Patients in the follow-up group had a higher overall mortality (HR=3.95) due to non-CRC causes (n=9, mean survival after ESD 23.7±13.7 months). During this follow-up time, tumour recurrence and disease-specific survival rates were not different between the groups (median follow-up 30 months; range: 6-105). CONCLUSION: Following ESD for a lesion at high risk of RD, follow-up only may be a reasonable choice in patients at high risk for surgery. Also, endoscopic resection quality should be improved. TRIAL REGISTRATION NUMBER: NCT03987828.
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BACKGROUND: Gastrointestinal (GI) fistula is a life-threatening condition and a therapeutic challenge. Endoscopic approaches include mucosal abrasion, clip closure, or stent diversion, with moderate success rates in the long term. We assessed whether fistula endoscopic submucosal dissection with clip closure (FESDC) could lead to complete resolution of fistulas even after failure of previous endoscopic therapy. METHODS: Patients with GI fistulas, including those with previous failed treatment, were retrospectively included. The primary outcome was long-term (>â3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with FESDC success. RESULTS: 23 patients (13 refractory 57â%) were included. Tight immediate sealing was achieved in 19 patients (83â%; 95â% confidence interval [CI] 61â%-95â%). Long-term closure was achieved in 14 patients (61â%; 95â%CI 39â%-80â%), with median follow-up of 20 months. Complications occurred in two patients (9â%). Previous local malignancy (Pâ=â0.08) and radiotherapy (Pâ=â0.047) were associated with a higher risk of failure. CONCLUSION: This novel FESDC strategy was demonstrated to be safe and feasible for permanent endoscopic closure of GI fistulas. Further studies are warranted to determine the place of this technique in the management of chronic GI fistula.
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Fístula do Sistema Digestório , Ressecção Endoscópica de Mucosa , Fístula , Fístula do Sistema Digestório/etiologia , Fístula do Sistema Digestório/cirurgia , Ressecção Endoscópica de Mucosa/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/métodos , Fístula/etiologia , Humanos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety. PATIENTS AND METHODS: This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered. RESULTS: A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (n = 135, 60.3%). Antibiotic prophylaxis was administered to 170 patients (75.2%) during 3.93 ± 3.46 days [1-21]. The overall adverse events rate was 9.3% (n = 21). Antibiotic prophylaxis was associated with the occurrence of adverse events (p = .003), but had no impact on their severity (p = .238). Antibiotic prophylaxis didn't influence the effectiveness of POEM (1 [0-4] vs 1 [0-9], p = .231). The use of a liquid diet in the 48 h prior to the procedure was significantly associated with a lower adverse events rate (3.1% vs 6.19%, p = .0002). CONCLUSION: The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.
Assuntos
Acalasia Esofágica , Transtornos da Motilidade Esofágica , Transtornos Motores , Miotomia , Cirurgia Endoscópica por Orifício Natural , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Adolescente , Estudos Retrospectivos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Transtornos Motores/etiologia , Resultado do Tratamento , Transtornos da Motilidade Esofágica/cirurgia , Transtornos da Motilidade Esofágica/etiologia , Miotomia/métodos , Esfíncter Esofágico Inferior/cirurgiaRESUMO
BACKGROUND AND AIMS: Colonic endoscopic submucosal dissection (ESD) is particularly challenging and limited to a few expert centers. We recently conducted a pilot study on improvement of colonic ESD with systematic use of a countertraction device (double-clip traction with rubber band [DCT-ESD]). METHODS: A French prospective multicenter study was conducted between March 2017 and September 2019, including all consecutive cases of naive colonic ESD. Since the first case of DCT-ESD in March 2017, all cases of colonic ESD have been performed using the DCT-ESD strategy in the 3 centers involved in the study. RESULTS: Five hundred ninety-nine lesions with a mean size of 53 mm were included in this study, resected by 5 operators in 3 centers. The en bloc, R0, and curative resection rates were 95.7%, 83.5%, and 81.1%, respectively. The adverse event rates were 4.9% for perforation and 4.2% for postprocedure bleeding. Between 2017 and 2019, the rates of R0 and curative resections increased significantly from 74.7% in 2017 to 88.4% in 2019 (P = .003) and from 72.6% in 2017 to 86.3% in 2019 (P = .004), respectively. Procedure duration and speed of resection were 62.4 minutes and 39.4 mm2/minute, respectively. No differences were noted between operators. CONCLUSION: DCT-ESD is a safe and reproducible technique, with results comparable with those of the large Japanese teams with speed of resection twice as high as previously reported studies. The DCT strategy is promising, cheap, and seems to be reproducible. Physicians performing colonic ESD should be aware of this promising tool to improve their results in ESD.
Assuntos
Ressecção Endoscópica de Mucosa , Dissecação , Humanos , Projetos Piloto , Estudos Prospectivos , Instrumentos Cirúrgicos , Tração , Resultado do TratamentoRESUMO
BACKGROUND: Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis. METHODS: This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up.âThe primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI). RESULTS: 76 patients were included (60.5â% women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45â% (interquartile range [IQR] 29â%â-â67â%). The median GCSI before G-POEM was 3.6 (IQR 2.8â-â4.0). Clinical success was achieved in 65.8â% of the patients at 1 year, with a median rate of reduction in the GCSI score of 41â%. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95â% confidence interval [CI] 1.01â-â11.54; Pâ=â0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95â%CI 0.95â-â1.00; Pâ=â0.03). CONCLUSIONS: The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8â% clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.
Assuntos
Acalasia Esofágica , Gastroparesia , Piloromiotomia , Esfíncter Esofágico Inferior , Feminino , Seguimentos , Esvaziamento Gástrico , Gastroparesia/etiologia , Gastroparesia/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Piloromiotomia/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Different treatments exist for Zenker diverticulum. We compared flexible endoscopic myotomy of the cricopharyngeal muscle, using a technique called the "window technique" in order to improve the field of view, to surgical approaches. MATERIALS AND METHODS: Patients were retrospectively included and divided into a gastrointestinal group, with flexible endoscopic myotomy, and an ear-nose-throat treatments group with either rigid endoscopic treatment, either cervicotomy. We evaluated effectiveness in terms of quality of life (on a scale on 0 to 10) safety and technical aspects of each procedure. RESULTS: A total 106 patients who underwent 128 interventions were included. Rigid endoscopic procedures were the shortest (p < 0.001), with no difference for adverse event. Endoscopic approaches, flexible and rigid ones, were associated with shorter time to intake resumption (1 and 3 days, respectively, vs 6 after cervicotomy) and shorter length of hospital stay (3 and 4 days, respectively, vs 7 after cervicotomy) (p = 0.001). Post-operative QoL was better after flexible endoscopy (9/10) and open cervicotomy (9/10) than after rigid endoscopy (7/10) (p = 0.004). Patients declared fewer residual symptoms after open cervicotomy (77% of low symptomatic patients) and flexible endoscopy (80%) than after rigid endoscopy (43%) (p = 0.003). Conversion to open surgery was more frequent during rigid than flexible endoscopies (18% vs 0%, p = 0.0008). CONCLUSION: Flexible endoscopic approach of Zenker diverticulum treatment seems to be safe and effective and may be an alternative to surgical approaches. Myotomy can be eventually helped by the window technique.