Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty.

BACKGROUND AND STUDY AIM: The role of colorectal endoscopic submucosal dissection (ESD) is standardized in Japan and East Asia, but technical difficulties hinder its diffusion. The aim was to identify predictors of difficulty for each neoplasm type. METHODS: A competent operator performed all procedures. ESD difficulty was defined as: en bloc with a slow speed (< 0.07 cm 2 /min; 30 × 30 mm neoplasm in > 90 min), conversion to endoscopic mucosal resection, or resection abandonment. Pre- and intraoperative difficulty variables were defined according to standard criteria, and evaluated separately for the rectum and colon. Difficulty predictors and gradients were evaluated by the multivariate logistic regression model. RESULTS: A total of 140 ESDs were included: 110 in the colon and 30 in the rectum. Neoplasms were laterally spreading tumors - granular type (LST-G) in 85 cases (61 %); the median longer axis was 30 mm (range 15 - 180 mm); a scar was present in 15 cases (11 %). ESD en bloc resection and difficulty rates were 85 % (n = 94) and 35 % (n = 39) in the colon, and 73 % (n = 22) and 50 % (n = 15) in the rectum ( P  = 0.17 and 0.28, respectively). The scar was the only preoperative predictor of difficulty in the rectum (odds ratio [OR] 12.3, 95 % confidence interval [CI] 1.27 - 118.36), whereas predictors in the colon were: scar (OR 12.7, 95 %CI 1.15 - 139.24), LST - nongranular type (NG) (OR 10.5, 95 %CI 1.20 - 55.14), and sessile polyp morphology (OR 3.1, 95 %CI 1.18 - 10.39). Size > 7 - ≤ 12 cm 2 (OR 0.20, 95 %CI 0.06 - 0.74) and operator experience > 120 procedures (OR 0.19, 95 %CI 0.04 - 0.81) were predictors for a easy procedure. No intraoperative predictors of difficulty were identified in the rectum, whereas predictors in the colon were: severe submucosal fibrosis (OR 21.9, 95 %CI 2.11 - 225.64), ineffective submucosal exposure by gravity countertraction (OR 12.3, 95 %CI 2.43 - 62.08), and perpendicular submucosal dissection approach (OR 5.2, 95 %CI 1.07 - 25.03). When experience was /= 90, preoperative gradient of colonic ESD difficulty was the highest for LST-NGs (scar positive and negative up to 47 % and 20 %, respectively), intermediate for sessile polyps with scar (up to 23 %), and the lowest for LST-Gs (< 8 %). Different difficulty gradients between neoplasm types persisted with increasing experience: LST-NG rate up to 14 % after 120 procedures. CONCLUSIONS: Colonic and rectal ESD difficulty has qualitative differences. Preoperative predictors should be considered to identify the difficulty gradient of each neoplasm type and the appropriate setting for ESD.

Heterotopic gastric mucosa in the anus and rectum: first case report of endoscopic submucosal dissection and systematic review.

BACKGROUND: Heterotopic gastric mucosa (HGM) is the most reported epithelial heterotopia, but it is very rare in the rectum and anus. METHODS: The first case of an asymptomatic adult male with a large nonpolypoid HGM in the low rectum underwent complete resection by endoscopic submucosal dissection (ESD) is reported. The systematic review was based on a comprehensive search of MEDLINE, EMBASE and Google Scholar. Studies on humans were identified with the term 'heterotopic gastric mucosa in the rectum and /or anus.' RESULTS: The search identified 79 citations, and 72 cases were evaluated comprising the present report. Congenital malformations were observed in 17 (24%) patients; rectal duplication accounted for most of the cases. The HGM was located in the anus and perineal rectum in 25 cases (41%) and low, middle and proximal pelvic rectum in 20 (33%), five (8%) and 11 cases (18%), respectively. Morphology was nonpolypoid in 37 cases (51%), polypoid in 26 cases (36%) and ulcerated in nine cases (13%). Specific anorectal symptoms were reported by 50 (69%) patients of the whole study population, and by 33 (97%) of 34 patients ≤ 18 years. Complications were observed in 23 cases (32%). The HGM was excised in 50 cases (83%). Endoscopic resection was performed in 17 cases (34%); resection was piecemeal in five of 12 lesions ≥15 mm, required argon plasma coagulation in two cases and was associated with residual tissue in two (17%). Intestinal metaplasia and an adenoma with low-grade dysplasia were described in three adults (4%). DISCUSSION: This systematic review shows that the HGM in the rectum and anus may be associated with specific rectal symptoms and serious complications, mainly in the pediatric population, and a risk of malignancy in adults. Its complete excision should be recommended, and the ESD can overcome the technical limits of conventional endoscopic snare resection and avoid unnecessary surgery.

Curative endoscopic submucosal dissection of large nonpolypoid superficial neoplasms in ulcerative colitis (with videos).

BACKGROUND: Endoscopic resection of superficial neoplasms in inflammatory bowel disease (IBD) is appropriate if a complete resection can be achieved. However, EMR is ineffective for large, nonpolypoid neoplasms in IBD due to submucosal fibrosis, and no data are available on the efficacy of endoscopic submucosal dissection (ESD). OBJECTIVE: To assess ESD feasibility and efficacy for large, nonpolypoid neoplasms in patients with IBD. DESIGN: Prospective case series. SETTING: Multicenter: Italian and Japanese centers. PATIENTS: Consecutive patients with long-standing ulcerative colitis and a superficial nonpolypoid neoplasm, >20 mm within the colitic mucosa. INTERVENTION: Neoplasm characterization and delineation by chromoscopy and narrow-band imaging. ESD performed according to the standard technique. MAIN OUTCOME MEASUREMENTS: Feasibility, safety, curative resection rates. RESULTS: Nine patients with 10 neoplasms were included (7 and 3 in the Italian and Japanese centers, respectively). Neoplasms were laterally spreading tumors-non-granular in 5 cases, in the left side of the colon in 7, had median size of 33 mm, and were associated with scar in 5 cases. Margin delineation was difficult in 5 cases. Submucosal fibrosis was present in 9 cases. ESD was en bloc with negative margins (R0) in 8 cases, and curative in 7. No endoscopic invisible dysplasia or cancer was found during the follow-up (median 24 months, range 6-72 months) at the resection site and elsewhere within the colitic mucosa. LIMITATIONS: Small series. CONCLUSION: ESD achieves curative resections in patients with IBD, but the procedure is difficult because of the high prevalence of submucosal fibrosis. Patients need to be accurately evaluated before resection and adhere to strict long-term follow-ups.

Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves.

BACKGROUND: Endoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed. OBJECTIVE: To evaluate a stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol. DESIGN: Prospective study in the Western setting. SETTING: This study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD. PATIENTS: Indications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis. INTERVENTION: Training consisted of 5 unsupervised ESDs on isolated stomach, an observation period at an ESD expert Japanese center, 1 supervised ESD on isolated stomach, and retraining on 1 rectal ESD under supervision. The operative training on patients was performed without supervision moving from the rectum to the colon according to the competence achieved. MAIN OUTCOME MEASUREMENTS: Competence was defined as an 80% en bloc resection rate plus a statistically significant reduction in operating time per square centimeter. Learning curves were calculated based on consecutive blocks of 5 procedures. RESULTS: From February 2009 to February 2012, 30 rectal and 30 colonic ESDs were performed. The rectal ESD learning curve showed that the en bloc resection rate was 80% after 5 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .0079); perforation occurred in 1 patient. The colonic ESD learning curve showed that the en bloc resection rate was 80% after 20 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .031); perforations occurred in 2 patients. LIMITATIONS: Single-center design. CONCLUSIONS: A minimal intensive training seems sufficient for endoscopists expert in therapeutic procedures to take up ESD in a not overly arduous incremental method with separate and sequential learning curves for the rectum and colon.

Micronutrient-enriched rapeseed oils reduce cardiovascular disease risk factors in rats fed a high-fat diet.

Many epidemiological studies have demonstrated that vegetable food consumption is associated with a reduced risk of cardiovascular diseases. The beneficial effects have been attributed to the content of bioactive molecules present in large quantities in plant food. The main proposal of this study was to evaluate in vivo whether micronutrient-enriched rapeseed oils (optimised oils) obtained using different crushing and refining procedures and characterised by different quantities and qualities of micronutrients, could have any beneficial effect on lipid profile and antioxidant status of plasma and liver. Sprague-Dawley rats were fed a high-fat diet for 4 weeks. The lipid source consisted of 20% optimised rapeseed oils with different quantities and qualities of micronutrients. The control group received traditional refined rapeseed oil. The experimental optimised oils all had a hypolipidaemic effect. In the group fed the highest levels of micronutrients, the reduction in plasma and hepatic triglycerides reached 25% and 17%, respectively, that of cholesterol 20% and 14%, respectively. In plasma, the ferric antioxidant capacity, superoxide dismutase, glutathione peroxidase and reduced glutathione significantly increased and lipid peroxidation decreased in parallel with the enhancement of micronutrients. The same trend was observed in the liver, except for glutathione peroxidase which was not affected by optimised oils. These results indicate that a regular intake of optimised rapeseed oils can help to improve lipid status and prevent oxidative stress, providing evidence that optimised oils could be a functional food with potentially important cardioprotective properties.

Intramuscular forearm metastasis as an initial presentation of bronchial adenocarcinoma.

Painful soft tissue masses may in rare instances correspond to intramuscular metastases from an unknown malignant neoplasia. We report an unusual case of a muscular metastasis to the flexor compartment of the forearm as the first clinical manifestation of an asymptomatic bronchial adenocarcinoma in a 46-old-year man.