Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study.

BACKGROUND AND AIMS: Nonampullary small-bowel adenomas ≥10 mm are typically resected using cautery-based polypectomy, which is associated with significant adverse events. Studies have demonstrated the safety and efficacy of piecemeal cold snare EMR for removing large colon polyps. Our aim was to assess the safety and efficacy of cold snare EMR for removal of large adenomas in the small bowel. METHODS: A retrospective study of patients who underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm between January 2014 and March 2019 was conducted at a tertiary care medical center. Polyp characteristics at the time of index and surveillance endoscopy were collected. Primary outcomes were residual or recurrent adenoma (RRA) seen on surveillance endoscopy, polyp eradication rate, and number of endoscopic procedures required for eradication. Adverse events including immediate and delayed bleeding, perforation, stricture, pancreatitis, and postpolypectomy syndrome were assessed. RESULTS: Of 43 patients who underwent piecemeal cold snare EMR, 39 had follow-up endoscopy. Polyps ranged in size from 10 to 70 mm (mean, 26.5 mm). RRA was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P < .001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range, 1-6) endoscopic procedures. Only 1 patient (2.3%) had immediate postprocedural bleeding. No cases of perforation or postpolypectomy syndrome were seen. CONCLUSIONS: Piecemeal cold snare EMR may be a feasible, safe, and efficacious technique for small-bowel polyps >10 mm. Prospective, randomized studies are needed to assess how outcomes compare with traditional cautery-based polypectomy.

Updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Endoscopic resection (ER) has been a standard treatment modality for early gastric cancer with ignorable risks of lymph node metastasis. As for EGCs within expanded indications, endoscopic submucosal dissection (ESD) has considerable advantages over endoscopic mucosal resection (EMR) regarding higher rate of en bloc resection, complete resection, but lower risk of local recurrence. Previous meta-analyses comparing ESD with surgery for EGC are scarce and not robust to reach definitive conclusions. METHODS: We searched PubMed, Web of Science, EMBASE, Cochrane Library Databases and Google Scholar through July 2019 to identify studies evaluating ESD vs surgery for EGC. Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of enrolled studies. Patient baseline characteristics, procedure-related and prognosis outcomes, and adverse event data were extracted and pooled for analyses by the Review Manager 5.3 software. Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) were used to assess the quality of evidence. Trial Sequential Analysis (TSA) was conducted to weaken random error and enhance the reliability of evidence. RESULTS: Totally 18 retrospective studies, involving 5993 patients, were included. ESD benefits were 128.38 min shorter operation duration [95%CI: (-204.68, -52.09), P = 0.001], 7.13 days shorter hospital stay [95%CI: (-7.98, -6.28), P < 0.00001], lower risk of procedure-related death [OR = 0.21, 95%CI: (0.07, 0.68), P = 0.009], lower risk of overall complication [OR = 0.47, 95%CI: (0.34, 0.63), P < 0.00001]. ESD was also associated with lower costs and better quality of life. However, ESD had lower rate of en bloc resection [OR = 0.07, 95%CI: (0.03, 0.21), P < 0.00001], histologically complete resection [OR = 0.07, 95%CI: (0.03, 0.14), P < 0.00001], curative resection [OR = 0.06, 95%CI: (0.01, 0.27), P = 0.002], and higher rate of local recurrence [OR = 5.42, 95%CI: (2.91, 10.11), P < 0.00001], metachronous cancer [OR = 10.84, 95%CI: (6.43, 18.26), P < 0.00001], synchronous cancer [OR = 6.59, 95%CI: (1.96, 22.1), P = 0.002]. ESD also led to lower disease-free survival [HR = 4.58, 95%CI: (2.79, 7.52), P < 0.00001] and recurrence-free survival [HR = 1.99, 95%CI: (1.38, 2.87), P = 0.0002]. No significant differences in overall survival (OS) and disease-specific survival (DSS) between ESD and surgery were observed. CONCLUSIONS: ESD offers a method of less expensive, less trauma, faster recovery and better quality of life compared to surgery for EGC. However, ESD is associated with higher risk of recurrence without compromising OS and DSS. Strict and careful surveillance after ESD is needed. Recurrent EGCs following ESD can usually be detected in early stage and successfully managed by repeated ESD. Accordingly, ESD technique provides an alternative to surgical resection for highly selected EGC patients.

Effects of Early Initiation of Solid Versus Liquid Diet after Endoscopic Submucosal Dissection on Quality of Life and Postoperative Outcomes: A Prospective Pilot Randomized Controlled Trial.

BACKGROUND/AIMS: Feeding recommendations after endoscopic submucosal dissection (ESD) for gastric neoplasms are not established and based on clinical experience. METHODS: This was a prospective pilot randomized controlled trial. Patients undergoing ESD for gastric neoplasms were randomly assigned to solid (n = 50) or liquid diet (n = 50) groups. Beginning the day after hemostasis confirmation until discharge, the solid diet group started on a diet of rice porridge, whereas the liquid diet group started on a liquid diet, with gradual transition to solid food. The primary endpoint was delayed bleeding rate. The secondary endpoints were quality of life (QOL), ulcer-stage, hospital fees, and post-ESD symptoms. RESULTS: Delayed bleeding occurred in the solid diet group (2%) but not in the liquid diet group. The QOL evaluation using European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-STO22 showed better score in the solid diet group. The patients who felt dietary restriction at discharge was of a larger number in the liquid diet group (p = 0.019). More patients experienced appetite loss (p = 0.038), constipation (p = 0.022), and dietary restriction (p = 0.037) in the liquid diet group during hospitalization. The other endpoints were equivalent between the groups. CONCLUSION: Early initiation of solid foods after ESD is feasible and associated with higher QOL, potentially rendering conventional liquid diets unnecessary, although additional studies are needed (Trial registration number: UMIN000013297).

Blue rubber bleb nevus syndrome: our experience and new endoscopic management.

The aim of our study is to enhance the awareness of blue rubber bleb nevus syndrome (BRBNS) through the patients in our hospital and introduced a new measure of endoscopic intervention.A retrospective review of 5 patients, who were diagnosed as BRBNS in our hospital from January 2013 to January 2017, was conducted. Data were collected with regard to demographics, clinical presentation, endoscopic and imaging findings, management, and follow-up data.In total of 5 patients, the mean age was 28.8 years, range 16 to 44 years (male/female, 1/4) with the average initial age of onset 15.4 years. No family history was identified in our group. Physical examination showed multiple cutaneous lesions in 2 patients (40%, 2/5). All the 5 patients had gastrointestinal tract vascular malformations; stomach involved in 2 cases, large intestine in 2 cases, and small intestine involved in 3 cases. Lesions in the visceral organs and tissue were found in 1 patient. Gastrointestinal bleeding was its main symptom (3/5, 60%). Laboratory investigations revealed anemia in 4 patients and abnormality of coagulopathy in 2 patients with severe anemia. Conservative approach was recommended in 3 cases that included iron supplementation, drug hemostasis, and/or blood transfusion. An innovatively therapeutic approach with endoscopic submucosal dissection (ESD) procedure was used successfully in 1 patient with 2 polypoid BRBNS lesions in rectum.BRBNS is a very rare vascular malformation syndrome with unclear etiopathogenesis and noncurative treatments. ESD procedure was a feasible approach to remove the partial gastrointestinal lesions.