Endoscopic Submucosal Dissection for Resections Larger than 10 cm: Outcomes from a Portuguese Center.

Background: Endoscopic submucosal dissection (ESD) is a minimally invasive technique for en bloc resection of superficial neoplastic lesions, independent of their size. However, for giant gastrointestinal superficial neoplasia, the risk of invasive cancer is higher, and ESD is typically challenging. Despite the increasing literature on giant resections, data on their efficacy and safety are still lacking. Objective: The aim of this study was to describe ESD outcomes from a Portuguese center, compare them with other international studies, and analyze the possible risk factors influencing outcomes. Methods: We conducted a retrospective single-center review using a prospectively collected database, including patients with rectal ESD resections larger than 10 cm, between January 2016 and December 2021. Clinical, procedural, and pathological data were collected and analyzed. Revision of the literature for comparison with international results was done through PubMed. Data were analyzed and statistical analysis performed, using Microsoft Excel and SPSS, to identify significant risk factors. Results: The study included 15 rectal resections, with a mean diameter of 140.9 mm (range 105-270), corresponding to lesions of 125.9 mm (87-238). The overall en bloc resection rate was 100% (n = 15). According to ESGE criteria, procedure was considered curative in 53.3% (n = 8), non-curative with high risk in 13.3% (n = 2), and local-risk recurrence in 33.3% (n = 5). Adverse events occurred in 26.7% (n = 4): 1 minor perforation and 3 stenosis, most endoscopically managed. For non-curative resections with local-risk recurrence, surveillance without adjuvant therapy was performed in all cases. For high-risk non-curative resections, surgery was performed in 1 patient and adjuvant chemoradiation therapy in another. Follow-up (mean 16 months) demonstrated a recurrence rate of 0%. Statistical analysis revealed resection size ≥20 cm as a risk factor for perforation (p value 0.067), and involvement of ≥90% of the circumference and procedural time ≥4 h as risk factors for stenosis (p value 0.029 and 0.009, respectively). Conclusions: Although challenging, ESD for giant lesions seems effective and safe, with a still relevant rate of complications, which were mostly endoscopically treated. Rigorous characterization of lesions is crucial to predict and avoid complications or the need for therapy escalation.

Background: A dissecao endoscopica da submucosa (DES) e uma tecnica minimamente invasiva para ressecao em bloco de tumores superficiais, independentemente do seu tamanho. No entanto, nas neoplasias superficiais gastrointestinais gigantes, o risco de cancro invasivo esta aumentado e a DES e tipicamente desafiante. Apesar do incremento da literatura acerca de ressecoes gigantes, dados da sua eficacia e seguranca sao ainda escassos. Objetivo: Descricao de outcomes de DES de um centro portugues e comparacao com estudos internacionais. Analise de eventuais fatores de risco influenciando os outcomes. Métodos: Revisao retrospetiva de um centro, usando a sua base de dados prospectivamente colhida, incluindo pacientes com ressecoes rectais por DES maiores que 10 cm, entre janeiro 2016 e dezembro 2021. Dados clinicos, endoscopicos e patologicos foram colhidos e analisados. A literatura foi revista atraves do PubMed, para comparacao com resultados internacionais. A analise dos resultados e estatistica foi realizada, utilizando o Microsoft Excel e SPSS, para a identificacao de fatores de risco com impacto significativo nos outcomes. Resultados: O estudo incluiu um total de 15 ressecoes retais, com uma media de diametros de 140,9 mm (intervalo 105­270), correspondendo a lesoes 125,9 mm (intervalo 87­238). A taxa de ressecao em bloco foi de 100% (n = 15). Segundo os criterios da ESGE, o procedimento foi curativo em 53,3% (n = 8), nao curativo com alto risco em 13,3% (n = 2) e com risco de recorrencia local em 33,3% (n = 5). Eventos adversos ocorreram em 26,7% (n = 4): 1 microperfuracao e 3 estenoses, a maioria geridas endoscopicamente. Os 5 casos nao curativos com risco de recorrencia local ficaram apenas sob vigilancia. Nas resseccoes nao curativas de alto risco, um paciente foi submetido a cirurgia e outro a quimioradioterapia adjuvante. O follow-up (media de 16 meses) demonstrou uma taxa de recorrencia de 0%. A analise estatistica demonstrou o tamanho da resseccao ≥20 cm como fator de risco significativo para perfuracao (p value 0.067); e envolvimento de ≥ 90% da circunferencia do lumen e tempo de procedimento ≥4h como fatores de risco significativos para estenose (p value 0.029 e 0.009, respetivamente). Conclusão: Apesar de desafiante, a DES para lesoes gigantes parece eficaz e segura, com uma taxa de complicacoes importante, possiveis de tratamento endoscopico. A caracterizacao rigorosa destas lesoes e crucial para predizer e evitar complicacoes ou a necessidade de escalada terapeutica.

Western outcomes of circumferential endoscopic submucosal dissection for early esophageal squamous cell carcinoma.

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.

Predicting residual neoplasia after a non-curative gastric ESD: validation and modification of the eCura system in the Western setting: the W-eCura score.

OBJECTIVE: To evaluate the risk factors for lymph node metastasis (LNM) after a non-curative (NC) gastric endoscopic submucosal dissection (ESD) and to validate and eventually refine the eCura scoring system in the Western setting. Also, to assess the rate and risk factors for parietal residual disease. DESIGN: Retrospective multicentre multinational study of prospectively collected registries from 19 Western centres. Patients who had been submitted to surgery or had at least one follow-up endoscopy were included. The eCura system was applied to assess its accuracy in the Western setting, and a modified version was created according to the results (W-eCura score). The discriminative capacities of the eCura and W-eCura scores to predict LNM were assessed and compared. RESULTS: A total of 314 NC gastric ESDs were analysed (72% high-risk resection (HRR); 28% local-risk resection). Among HRR patients submitted to surgery, 25% had parietal disease and 15% had LNM in the surgical specimen. The risk of LNM was significantly different across the eCura groups (areas under the receiver operating characteristic curve (AUC-ROC) of 0.900 (95% CI 0.852 to 0.949)). The AUC-ROC of the W-eCura for LNM (0.916, 95% CI 0.870 to 0.961; p=0.012) was significantly higher compared with the original eCura. Positive vertical margin, lymphatic invasion and younger age were associated with a higher risk of parietal residual lesion in the surgical specimen. CONCLUSION: The eCura scoring system may be applied in Western countries to stratify the risk of LNM after a gastric HRR. A new score is proposed that may further decrease the number of unnecessary surgeries.

Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study.

Endoscopic submucosal dissection (ESD) in colorectal lesions is demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a piecemeal ESD resection, or after an en bloc resection but with positive horizontal margins (local-risk resection-LocRR), for colorectal benign neoplasia. A retrospective multicenter analysis of consecutive colorectal ESDs was performed. Patients with LocRR ESDs for the treatment of benign colorectal lesions with at least one follow-up endoscopy were included. A cohort of en bloc resected lesions, with negative margins, was used as the control. A total of 2255 colorectal ESDs were reviewed; 352 of the ESDs were "non-curative". Among them, 209 were LocRR: 133 high-grade dysplasia and 76 low-grade dysplasia. Ten cases were excluded due to missing data. A total of 146 consecutive curative resections were retrieved for comparison. Compared to the "curative group", LocRRs were observed in lengthier procedures, with larger lesions, and in non-granular LSTs. Recurrence was higher in the LocRR group (16/199, 8% vs. 1/146, 0.7%; p = 0.002). However, statistical significance was lost when considering only en bloc resections with positive horizontal margins (p = 0.068). In conclusion, a higher rate of residual lesion was found after a piecemeal ESD resection, but not after an en bloc resection with positive horizontal margins.

Outcomes and Learning Curve in Endoscopic Submucosal Dissection of Rectal Neoplasms with Severe Fibrosis: Experience of a Western Center.

Introduction: Endoscopic submucosal dissection (ESD) of lesions with severe submucosal fibrosis has been associated with worse outcomes, such as lower curative resection rate and higher incidence of adverse events. This study aims to investigate its true impact on rectal ESD performed in the West and to assess predictive factors of severe fibrosis. Methods: We conducted a retrospective study including all rectal ESDs performed at our tertiary center from January 2013 to January 2021. Lesions were grouped as nonsevere fibrosis or severe fibrosis. ESD outcomes, predictors of severe fibrosis, and the learning curve were evaluated. Results: ESD was performed in 195 lesions, 45 with severe fibrosis. Three resections were interrupted (one due to severe fibrosis). The presence of severe fibrosis was related to a significantly lower resection speed (16.93 mm2/min vs. 24.66 mm2/min, p = 0.007), en bloc (86.4% vs. 96.6%, p = 0.019), R0 (61.4% vs. 79.7%, p = 0.013), and curative (54.5% vs. 78.4%, p = 0.003) resection rates and a higher rate of hybrid ESD required to complete resection (13.6% vs. 2.0%, p = 0.005). No significant difference was noted regarding adverse events rate (18.2% vs. 8.1%, p = 0.09). Male sex, ulcerative colitis, pelvic radiotherapy, a lesion on the anastomotic site, previous manipulation, and deep submucosal invasion were independent predictors for severe fibrosis. En bloc resection rate improved during time (60.0% vs. 94.1%, p = 0.018). Conclusions: Severe submucosal fibrosis is an important factor related to noncurative resections and challenging rectal ESD. Factors predicting its severity are extremely important and could allow more experienced endoscopists to be assigned to more difficult cases, allowing safer procedures.

Introdução: A disseção endoscópica da submucosa (DES) de lesões com fibrose severa tem sido associada a piores resultados, nomeadamente uma menor taxa de ressecção curativa e maior taxa de complicações. Este estudo tem como objetivo investigar o impacto da fibrose severa na DES de lesões do reto realizada no ocidente e avaliar fatores preditivos de fibrose severa. Métodos: Foi realizado um estudo retrospetivo incluindo todas as DES de lesões do reto realizadas no nosso centro entre janeiro de 2013 e janeiro de 2021. As lesões foram agrupadas em lesões sem fibrose severa ou com fibrose severa. Foram analisados os resultados da DES, preditores de fibrose severa e a curva de aprendizagem. Resultados: Foi realizada DES em 195 lesões: 45 com fibrose severa. Três resseções foram interrompidas (uma devido a fibrose severa). A presença de fibrose severa associou-se a uma significativa menor velocidade de resseção (16.93 mm2/min vs. 24.66 mm2/min, p = 0.007) e significativas menores taxas de excisão em bloco (86.4% vs. 96.6%, p = 0.019), R0 (61.4% vs. 79.7%, p = 0.013) e curativa (54.5% vs. 78.4%, p = 0.003), bem como uma maior taxa de resseção híbrida necessária para completar a excisão (13.6% vs. 2.0%, p = 0.005). Não se verificou uma diferença estatisticamente significativa em relação aos efeitos adversos nos dois grupos (18.2% vs. 8.1%, p = 0.09). O sexo masculino, a presença de colite ulcerosa, radioterapia pélvica prévia, localização em anastomose, manipulação prévia ou invasão profunda da submucosa foram identificados como fatores preditores de fibrose severa. A taxa de excisão em bloco aumentou ao longo do tempo (60.0% vs. 94.1%, p = 0.018). Conclusão: A fibrose severa é um importante fator relacionado com excisões não curativas e mais complexas. A identificação de fatores proditores da sua gravidade é de extrema importância e pode permitir a alocação de endoscopistas mais experientes para casos mais difíceis, permitindo procedimentos mais seguros.

Risk of residual neoplasia after a noncurative colorectal endoscopic submucosal dissection for malignant lesions: a multinational study.

BACKGROUND : Endoscopic submucosal dissection (ESD) in colorectal lesions is technically demanding and a significant rate of noncurative procedures is expected. We aimed to assess the rate of residual lesions after a noncurative ESD for colorectal cancer (CRC) and to establish predictive scores to be applied in the clinical setting. METHODS : Retrospective multicenter analysis of consecutive colorectal ESDs. Patients with noncurative ESDs performed for the treatment of CRC lesions submitted to complementary surgery or with at least one follow-up endoscopy were included. RESULTS : From 2255 colorectal ESDs, 381 (17 %) were noncurative, and 135 of these were performed in CRC lesions. A residual lesion was observed in 24 patients (18 %). Surgery was performed in 96 patients and 76 (79 %) had no residual lesion in the colorectal wall or in the lymph nodes. The residual lesion rate for sm1 cancers was 0 %, and for > sm1 cancers was also 0 % if no other risk factors were present. Independent risk factors for lymph node metastasis were poor differentiation and lymphatic permeation (NC-Lymph score). Risk factors for the presence of a residual lesion in the wall were piecemeal resection, poor differentiation, and positive/indeterminate vertical margin (NC-Wall score). CONCLUSIONS : Lymphatic permeation or poor differentiation warrant surgery owing to their high risk of lymph node metastasis, mainly in > sm1 cancers. In the remaining cases, en bloc and R0 resections resulted in a low risk of residual lesions in the wall. Our scores can be a useful tool for the management of patients who undergo noncurative colorectal ESDs.

Endoscopic submucosal dissection: a country dissemination experience and outcomes.

OBJECTIVE: An increasing use of endoscopic submucosal dissection (ESD) has been reported in Western countries, although some differences in training schemes and outcomes have been described. We aimed to report the training model, implementation, and outcomes of ESD in Portugal. METHODS: All endoscopists trained at our center from our country (n = 9) were invited to a survey regarding: (a) training period; (b) ESD outcomes and (c) implementation of ESD in each respective center. RESULTS: All endoscopists completed the survey. Learning ESD was centered on human ESD assistance in a high-volume center during a median time of 6 months and complemented mainly by hands-on courses (89%). During the surveyed period, a total of 1229 ESD were performed, mostly in gastric locations (74%). Median complete R0 and curative resection rate were 92% (IQR, 81-96.8) and 87% (IQR, 74-93.3), respectively, and median perforation rate was 0.89% (IQR, 0.25-6.22). The main limitations encountered during the implementation of ESD were related to the lack of initial mentoring or insufficient expertise to progress to more difficult lesions. CONCLUSION: Learning ESD through participation in hands-on courses and visiting high-volume centers seems to be adequate to achieve a good competence at the initial stage of ESD, which in fact is in consonance with the European Society of Gastrointestinal Endoscopy recommendations. However, mentoring is essential for technical progression, and this represents the fundamental barrier during the adoption of ESD, which may be overcome by increasing hands-on training in animal or artificial simulators, but preferably with the implementation of a structured training program.

A "window" in the duodenal bulb: an atypical presentation of chronic cholecystitis.

A 74-year-old male presented with melena and fatigue, without fever or abdominal pain. Laboratory examination revealed anemia, leukocytosis, elevated C-reactive protein levels and conjugated hyperbilirubinemia with elevated liver enzymes. Upper endoscopy identified blood in the stomach and duodenum and a 6 mm hole in the anterosuperior surface of the duodenal bulb with spontaneous drainage of a bloody brownish content. The mucosa surrounding the hole was normal and there was a discrete mucosal flap that throbbed with air insufflation. Abdominal computed tomography identified a fistulous tract between the duodenal bulb and the gallbladder with a 2 mm caliber, suggesting a cholecystoduodenal fistula. Diagnosis is often difficult because symptoms are nonspecific and variable but gastrointestinal bleeding is a rare clinical presentation.

Reliability of Paris Classification for superficial neoplastic gastric lesions improves with training and narrow band imaging.

Background and study aims Paris Classification is used to classify gastrointestinal superficial neoplastic lesions and to predict presence of submucosal invasion. We aimed to evaluate interobserver reliability and agreement for this classification among Western endoscopists. Methods A total of 54 superficial gastric lesions were independently classified according to Paris classification by eight endoscopists (4 experts and 4 non-experts). Observers were asked to classify two sets of images - first, obtained with high-resolution white light (HR-WL) endoscopy and secondly, with the same HR-WL images paired with images obtained with high-resolution Narrow Band Imaging (HR-NBI) - HR-WL + NBI image group. Results Overall interobserver reliability when asked to classify in I, II or III was good both using HR-WL images and HR-WL + NBI images (wK of 0.65 and 0.70, respectively). The proportion of agreement for type III lesions was 0.48 for HR-WL images increasing to 0.74 in the HR-WL + NBI group. Interobserver reliability for identification of a IIc component was only moderate (wK 0,47). NBI improves both sensitivity and interobserver reliability among trainees (from wK 0.19 to 0.47). Specificity was higher than sensitivity in predicting submucosal invasion. Conclusion Overall, the reliability of Paris classification is moderate to good. Training on this classification or its revision and use of technology such as NBI may improve not only reliability and agreement but also accuracy.