Ambulatory Endoscopic Submucosal Dissection for Gastrointestinal Neoplasms: Trends and Associated Factors in the United States.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for superficial gastrointestinal (GI) cancers.1,2 ESD practice is expanding significantly in the United States and Western countries. This is attributed to a shorter hospital stay, better quality of life, and fewer adverse events compared with surgery. In the United States, ESD usually is performed and managed in an outpatient setting (ambulatory ESD) or with an overnight hospital stay. This practice is in contrast to Eastern Asian countries, where 3 to 5 days of hospital stay is a routine process for observation after ESD. A Swedish study showed that patients with well-selected colorectal neoplasms (median tumor size, 37 mm) could be managed safely in an outpatient setting after ESD.3 A North American multicenter ESD study also reported that ambulatory ESD was safe and feasible in selected cases (noninvasive cancers, no adverse events, high-volume endoscopists with short procedure time).4 However, procedural and technical aspects that enable safe outpatient management of patients after ESD need to be investigated.

The use of a self-assembling peptide gel for stricture prevention in the esophagus after endoscopic submucosal dissection: a U.S. multicenter prospective study (with video).

BACKGROUND AND AIMS: Postoperative stricture is a serious common adverse event after extensive endoscopic submucosal dissection (ESD) in the esophagus. Self-assembling peptide (SAP) gel has been shown to promote tissue healing and re-epithelialization. The aim of this study was to evaluate the effect of the SAP gel for esophageal stricture prevention after ESD. METHODS: This was a multicenter prospective study of patients who underwent esophageal ESD followed by SAP gel application between March 2022 and December 2023. Patients were included if the ESD mucosal defect involved ≥50% of the circumference of the esophagus. High-risk cases were defined as mucosal defects ≥75% of the circumference. Stricture was defined as the inability to pass an endoscope ≥8.9 mm in diameter or a narrow-caliber lumen in a patient with symptoms. RESULTS: A total of 43 patients (median age, 71 years; 81.4% male) underwent ESD (median resected specimen size, 50 mm) during the study period. SAP gel (median, 3 mL) was successfully applied in all cases (median time, 4 minutes). In aggregate, stricture occurred in 20.9% (9 of 43) of the cases. Stricture developed in 30.8% of the high-risk cases: 80% (4 of 5) after circumferential ESD and 19% (4 of 21) in those with defects ≥75% but <100% of the circumference. All cases of stricture resolved with endoscopic treatment. Three cases (6.9%) of postoperative bleeding occurred and were adequately managed endoscopically. CONCLUSIONS: We show that SAP gel application was easy, quick, and associated with a relatively low stricture rate comparable to other prophylactic methods. Additional comparative studies are needed to corroborate these preliminary findings.

Learning curve for endoscopic submucosal dissection (ESD) in the United States: Large, untutored, single-operator experience.

Background and study aims Endoscopic submucosal dissection (ESD) allows removal of tumors en-bloc. Western adoption of ESD has been hindered by its steep learning curve. Western data regarding ESD learning curve are limited. We analyzed the learning curve of a single endoscopist at a tertiary referral center in the United States. Patients and methods All consecutive ESDs performed by a single endoscopist at a tertiary referral center in the United States from 2015 through 2022 were identified. Descriptive statistics and CUSUM analysis were used to describe the learning curve for en-bloc, R0 resection, and resection speed. Results In our study, 503 patients with 515 lesions were included. Severe submucosal fibrosis was found in 17% of the lesions. The rates of en-bloc, R0, and curative resections were 81.9%, 71.1%, and 68.4%, respectively. CUSUM analysis showed that the learning curve plateaued at 268, 347, and 170 cases for en-bloc resection, R0 resection, and achieving a resection speed > 9 cm 2 /hr. Fibrosis significantly affected the R0 resection rate in the regression analysis (95% confidence interval 0.21-0.55). In colonic ESD curve analysis, the learning plateau was reached after 185 cases for both en-bloc and R0 resection. Conclusions Following ex-vivo training in an animal model, an untutored expert operator achieved competency in ESD between 250 and 350 procedures. Our data can inform development of future training programs in the West.

Transcecal endoscopic appendectomy for management of complex appendiceal polyps extending into the appendiceal orifice.

Background and study aims Endoscopic resection of appendiceal orifice (AO) polyps extending inside the appendiceal lumen is challenging given the inability to determine polyp lateral margins and risk of appendicitis. Transcecal endoscopic appendectomy (TEA) ensures en bloc resection of these complex polyps. Patients and methods This case series includes patients who underwent TEA by a single endoscopist in the United States. Technical success was defined as achieving complete removal of the appendix along with AO polyp in an en bloc fashion. Results In total, nine patients were included (mean age 69.7 ± 9.6 years). The average appendix size was 4.07 ± 2.02 cm. Technical success was achieved in 100% of the patients. The average procedure length was 118.1 ± 44.21 minutes. The en bloc resection rate, R0 resection rate, and curative resection rates were 100%. Patients were observed for an average of 3.1 ± 1.6 days. One patient developed loculated fluid collection 9 days post procedure, which resolved on its own with oral antibiotic therapy. No other adverse events were recorded. Conclusions This was an early study of the feasibility of TEA in the United States. This novel technique, in early-stage development, is potentially safe and associated with a minimal risk profile in expert hands. Further prospective studies are needed to standardize the technique.

Outcomes of endoscopic submucosal dissection in cirrhotic patients: First American cohort.

BACKGROUND: Among patients with cirrhosis and pre-malignant or early malignant mucosal lesions, surgical intervention carries a much higher bleeding risk. When such lesions are discovered, endoscopic submucosal dissection (ESD) may offer curative therapy with lower risks than surgery and improved outcomes compared to traditional endoscopic resection. AIM: To evaluate the outcomes of ESD in patients with cirrhosis. METHODS: Patients with cirrhosis undergoing ESD between July 2015 and August 2022 were retrospectively matched in 1:2 fashion to controls based on lesion location, size, and anticoagulation use. Procedural outcomes were compared between groups. RESULTS: A total of 64 Lesions from 59 patients were included (16 cirrhosis, 43 control). There were no differences in patient or lesion characteristics between groups. En bloc and curative resection was achieved in 84.21%, 78.94% of the cirrhosis group and 88.89%, 68.89% of controls, respectively, with no significant differences. Cirrhotic patients had significantly higher rates of intra-procedural coagulation grasper use for control of bleeding (47.37% vs 20%; P = 0.02). There were otherwise no significant differences in adverse event rates. In the 29 patients with follow up, we found higher rates of recurrence in the cirrhosis group compared to controls (40% vs 5.26%; P = 0.019), however this effect did not persist on multivariable analysis controlling for known confounders. CONCLUSION: ESD may be safe and effective in patients with cirrhosis. Most procedure related outcomes were not significantly different between groups. Intra-procedural bleeding requiring use of the coagulation grasper use was expectedly higher in the cirrhosis group given the known effects of liver disease on hemostasis.

Expanding endoscopic boundaries: Endoscopic resection of large appendiceal orifice polyps with endoscopic mucosal resection and endoscopic submucosal dissection.

BACKGROUND: Large appendiceal orifice polyps are traditionally treated surgically. Recently, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been utilized as alternative resection techniques. AIM: To evaluate the efficacy and safety of endoscopic resection techniques for the management of large appendiceal orifice polyps. METHODS: This was a retrospective observational study conducted to assess the feasibility and safety of EMR and ESD for large appendiceal orifice polyps. This project was approved by the Baylor College of Medicine Institutional Review Board. Patients who underwent endoscopic resection of appendiceal orifice polyps ≥ 1 cm from 2015 to 2022 at a tertiary referral endoscopy center in the United States were enrolled. The main outcomes of this study included en bloc resection, R0 resection, post resection adverse events, and polyp recurrence. RESULTS: A total of 19 patients were identified. Most patients were female (53%) and Caucasian (95%). The mean age was 63.3 ± 10.8 years, and the average body mass index was 28.8 ± 6.4. The mean polyp size was 25.5 ± 14.2 mm. 74% of polyps were localized to the appendix (at or inside the appendiceal orifice) and the remaining extended into the cecum. 68% of polyps occupied ≥ 50% of the appendiceal orifice circumference. The mean procedure duration was 61.6 ± 37.9 minutes. Polyps were resected via endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid procedures in 5, 6, and 8 patients, respectively. Final pathology was remarkable for tubular adenoma (n = 10) [one with high grade dysplasia], sessile serrated adenoma (n = 7), and tubulovillous adenoma (n = 2) [two with high grade dysplasia]. En bloc resection was achieved in 84% with an 88% R0 resection rate. Despite the large polyp sizes and challenging procedures, 89% (n = 17) of patients were discharged on the same day as their procedure. Two patients were admitted for post-procedure observation for conservative pain management. Eight patients underwent repeat colonoscopy without evidence of residual or recurrent adenomatous polyps. CONCLUSION: Our study highlights how endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid procedures are all appropriate techniques with minimal adverse effects, further validating the utility of endoscopic procedures in the management of large appendiceal polyps.