Endoscopic submucosal dissection for anorectal tumor with hemorrhoids close to the dentate line: a multicenter study of Hiroshima GI Endoscopy Study Group.

BACKGROUND: The lower rectum close to the dentate line has distinct characteristics, making endoscopic submucosal dissection (ESD) of tumors challenging. We assessed clinical outcomes of ESD for such patients with hemorrhoids. METHODS: Sixty-four patients (mean age, 68 years) underwent ESD for anorectal tumors close to the dentate line. We divided patients into those with (Group A, 45 patients) and without hemorrhoids (Group B, 19 patients). We examined en bloc and histological en bloc resection rates, procedure time, complication rates, and postoperative prognosis after ESD. RESULTS: The mean tumor size was 43 mm. Histologic diagnoses were adenoma (42 %, 27/64), carcinoma in situ (44 %, 28/64), and T1 carcinoma (14 %, 9/64). There was no significant difference in en bloc resection (93 %, 42/45 vs. 95 %, 18/19) or postoperative bleeding rates (16 %, 7/45 vs. 11 %, 2/19) between Groups A and B, respectively. The mean procedural durations were 120 and 124 min, respectively, in Groups A and B. No perforations occurred. There was no significant difference in postoperative anal pain rate between Groups A (18 %, 8/45) and B (16 %, 3/19), and it resolved within a few days in all cases. There was one case of stricture in Group B. Two patients with T1 carcinoma underwent additional surgery, one underwent chemotherapy, and five had no additional treatment. No recurrence occurred during the follow-up period of 38 months. CONCLUSIONS: ESD is safe and effective for anorectal tumors close to the dentate line in patients with hemorrhoids.

Predictors of incomplete resection and perforation associated with endoscopic submucosal dissection for colorectal tumors.

BACKGROUND AND OBJECTIVE: Colorectal endoscopic submucosal dissection (ESD) is technically challenging. Our aim was to identify predictors of incomplete resection and perforation in colorectal ESD. DESIGN: Retrospective study. SETTING: Academic Japanese endoscopy unit. PATIENTS AND MAIN OUTCOME MEASUREMENTS: A total of 267 consecutive cases of colorectal tumors treated by ESD from May 2010 to February 2013 were analyzed. Predictors of incomplete resection and perforation, including lesion size, growth type, pathological diagnosis, use of hemostatic forceps, degree of fibrosis, history of biopsy, history of local endoscopic treatment, and endoscopic operability. RESULTS: The incomplete resection rate was 4.1%. The perforation rate was 5.6%. Univariate analysis identified severe fibrosis (P = .032), submucosal (SM) deep (>1000 µm) invasion (P = .033) and poor endoscopic operability (P = .030) as predictors of incomplete resection, and severe fibrosis (P = .038), postendoscopic treatment (P = .016), and poor endoscopic operability (P = .012) as predictors of perforation. Multivariate analysis identified poor endoscopic operability and SM deep invasion as independent predictors of incomplete resection, and poor endoscopic operability and severe fibrosis as independent predictors of perforation. There was no adjustment of P values for multiple testing. LIMITATION: A single-center study by a single colonoscopist. All statistical results should be taken as descriptive only. CONCLUSIONS: Poor endoscopic operability and SM deep invasion were significant independent predictors of incomplete resections. Poor endoscopic operability and severe fibrosis were significant independent predictors of perforation. These features may provide helpful information when planning colorectal ESD.

Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms.

PURPOSE: Although delayed bleeding is a major complication of endoscopic submucosal dissection (ESD) for colorectal neoplasms, few reports have assessed the risk factors for delayed bleeding after colorectal ESD. METHODS: This study included 363 consecutive patients in whom 377 colorectal neoplasms were resected using ESD between April 2006 and August 2012. We classified patients and lesions into two groups on the basis of presence or absence of delayed bleeding and retrospectively compared the clinicopathological characteristics and clinical outcomes of ESD between the two groups. RESULTS: Delayed bleeding occurred in 25 (6.6 %) of 377 lesions, and all cases of delayed bleeding were successfully controlled by endoscopic procedures. With respect to patient-related factors, there was no significant difference between the groups in mean age, sex ratio, and current use of antithrombotic agents. With respect to lesion-related factors, there was no significant difference between the groups in mean lesion size, growth pattern, and mean procedure time (p = 0.6). Lesions located in the rectum (vs colon, p = 0.0005) and lesions with severe submucosal fibrosis (vs no or mild fibrosis, p = 0.022) were significantly related to delayed bleeding. Upon multivariate analysis, lesions located in the rectum (vs colon, odds ratio 4.19; p = 0.0009) were significantly related to delayed bleeding after colorectal ESD. CONCLUSIONS: This study demonstrated that location of lesions in the rectum was a significant independent risk factor for delayed bleeding after ESD for colorectal neoplasms.

Risk factors for vertical incomplete resection in endoscopic submucosal dissection as total excisional biopsy for submucosal invasive colorectal carcinoma.

PURPOSE: Endoscopic submucosal dissection (ESD) for colorectal tumor is a minimally invasive treatment. Histologic information obtained from the entire ESD specimen is important for therapy selection in submucosal invasive colorectal carcinoma (SMca). This study aimed to identify risk factors for vertical incomplete resection (vertical margin-positive [VM+]) when ESD was performed as total excisional biopsy for SMca. METHODS: From June 2003 through December 2011, 78 SMca cases were resected by ESD at Hiroshima University Hospital. Patient and tumor characteristics, intraoperative variables, and histopathology were compared between the VM+ group and the vertical complete resection (vertical margin-negative) group. The ability of magnifying endoscopy (ME) and endoscopic ultrasonography (EUS) to predict VM+ was assessed. RESULTS: ESD resulted in VM+ in eight cases (10.3 %), with a greater percentage invading to a depth of ≥2,000 vs. <2,000 µm (P = 0.047). Severe submucosal fibrosis was found in five of the eight cases (62.5 %, P = 0.017). Poor differentiation was seen at the deepest invasive portion in six cases (75.0 %), and two of six cases had an invasion depth <2,000 µm. Of 39 EUS cases, 36 not showing deep invasion close to the muscularis propria were completely resected by ESD. CONCLUSIONS: Submucosal fibrosis and poor differentiation at the deepest invasive portion may be risk factors for VM+ in colorectal ESD for tumors with submucosal deep invasion. ME plus EUS is more likely to help determine whether ESD is indicated as complete total excisional biopsy for SMca.

Clinical usefulness of narrow band imaging magnifying colonoscopy for assessing ulcerative colitis-associated cancer/dysplasia.

Background and study aims: Colitis-associated cancer/dysplasia (CC/D) can affect the life expectancy of patients with ulcerative colitis (UC). Although the utility of magnifying chromocolonoscopy has been shown, the use of optical magnification with narrow band imaging (NBI) for distinguishing CC/D from non-neoplastic lesions in patients with UC has not been reported. We evaluated whether endoscopic findings are distinguishing and thus assessed the clinical usefulness of NBI magnification for differentiating UC-associated lesions. Patients and methods: The study involved 27 patients diagnosed and treated at Hiroshima University Hospital between September 2005 and March 2015: a neoplasia group (16 lesions) and a non-neoplasia group (17 lesions). The neoplasias comprised 9 dysplastic lesions, 5 intramucosal carcinomas, and 2 submucosal carcinomas, and 17 non-neoplastic lesions. Targeted biopsy samples of suspicious lesions detected by conventional colonoscopy were classified pathologically as neoplastic or non-neoplastic, and NBI magnifying colonoscopy findings (i. e., the surface [unclear/regular/irregular/amorphous] and vascular [same as the background mucosa/regular/irregular/avascular] patterns) of the 2 lesion types were compared. Results: Irregular/amorphous surface patterns were significantly more common in neoplastic lesions than in non-neoplastic lesions (81 % [13/16] vs. 18 % [3/17], respectively, P < 0.001). Irregular/avascular vessel pattern tended to be more common in neoplastic lesions (75 % [12/16] vs. 41 % [7/17], respectively). The surface pattern correctly predicted 82 % of neoplastic lesions, and the vessel pattern correctly predicted 67 % of non-neoplastic lesions. The 2 endoscopic findings together correctly predicted 91 % of neoplastic lesions. Conclusion: Surface pattern, determined by magnifying colonoscopy with NBI, is useful for differenting between UC-associated neoplastic and non-neoplastic lesions.

Clinical usefulness of a single-use splinting tube for poor endoscope operability in deep colonic endoscopic submucosal dissection.

BACKGROUND AND STUDY AIMS: Poor endoscope operability remains a significant challenge during colorectal endoscopic submucosal dissection (ESD). We retrospectively evaluated the experience and clinical usefulness of a new single-use splinting tube in deep colonic ESD in the setting of poor scope operability. PATIENTS AND METHODS: Among 691 patients with colorectal tumors treated with ESD at Hiroshima University Hospital between November 2009 and July 2015, we analyzed 20 consecutive patients who underwent deep colonic ESD using a single-use splinting tube because of poor scope operability. Poor operability was defined as paradoxical movement of the endoscope, poor control with adhesions, and lesion motion with heartbeat or breathing. Technical and clinical success rates and adverse events were assessed. RESULTS: Paradoxical movement and poor control with adhesions were improved in all cases using the single-use splinting tube. The en bloc resection rate was 95 % (19/20) and histological en bloc resection rate was 100 % (20/20). There were no complications related to use of the splinting tube. CONCLUSIONS: Use of a single-use splinting tube helped to overcome poor scope operability in deep colonic ESD.

Clinical impact of dual red imaging in colorectal endoscopic submucosal dissection: a pilot study.

BACKGROUND: Dual red imaging (DRI), a novel image-enhanced endoscopic technique, is expected to improve visibility of thin vessels, but no reports of the clinical use of DRI in colorectal endoscopic submucosal dissection (ESD) have been published. We aimed to compare the visibility of vessels, demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine, and fibrosis on DRI with that on white light imaging (WLI). We applied the principle of DRI to the image of the submucosal layer during colorectal ESD as a pilot study. METHODS: A total of seven physicians compared 17 DRI images to the corresponding WLI images in colorectal ESD. The physicians compared the number of arteries identified on DRI with the actual number of arteries. The physicians rated the visibility of vessels, the demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine, and fibrosis. Inter-observer agreement was also examined using the kappa statistic. RESULTS: Visibility of vessels and the demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine improved with the use of DRI compared with that using WLI. DRI can discriminate between arteries and veins clearly through the color of the vessels. CONCLUSIONS: DRI improves the visibility of vessels, especially that of arteries, as they appear orange, and the demarcation line of the muscle layer. DRI may help to make colorectal ESD safer and faster.

Clinical usefulness of endocytoscopy in the remission stage of ulcerative colitis: a pilot study.

BACKGROUND: Histopathology can be used to detect ulcerative colitis (UC) relapse, but diagnosis of the disease activity by histopathology requires multiple biopsies to be taken. Magnifying endocytoscopy provides a method for real-time ultra-magnifying imaging. It was recently reported that the endocytoscopy system score (ECSS) correlates well with the histopathology of UC. Here we evaluated the clinical usefulness of endocytoscopy for accurately monitoring UC during remission. METHODS: We performed endocytoscopy on 26 patients with UC in remission that had been diagnosed by conventional colonoscopy at our institution between January and April 2013. Endocytoscopy was performed at the area of the rectum where UC had been detected with conventional endoscopy. Biopsies were also taken from the same area and histopathology was evaluated by a single pathologist according to the Matts' grading system. The correlation between the relapse rate of UC and both the ECSS and the Matts' histopathological grade was evaluated. RESULTS: The ECSS of the intestinal mucosa in UC showed a correlation with the Matts' histopathological grade (Spearman's |r| = 0.647). The patients were classified into two groups: those with an ECSS of 0-2 (Grade A, 12 cases) and those with an ECSS of 3-6 (Grade B, 10 cases). To date, three Grade B cases have relapsed and no Grade A cases have relapsed. The average post-endocytoscopy surveillance period was 446 ± 92 days. CONCLUSIONS: The ECSS may be a predictive indicator for UC relapse since there was a correlation between the ECSS and the degree of inflammation as determined by histopathology.

Risk of bleeding after endoscopic submucosal dissection for colorectal tumors in patients with continued use of low-dose aspirin.

BACKGROUND: Although Japanese guidelines proposed by the Japan Gastroenterological Endoscopy Society for endoscopic submucosal dissection (ESD) for colorectal tumors recommend continued use of low-dose aspirin (LDA), this strategy is controversial. It was our practice to interrupt LDA therapy 5-7 days before ESD until December 2010, when we instituted the new guidelines and performed ESD without interrupting LDA therapy. The aim of the present study was to confirm the validity of the noninterrupted use of LDA inpatients undergoing ESD for colorectal tumors. METHODS: We studied 582 consecutive patients with 609 colorectal tumors who underwent ESD at Hiroshima University Hospital between January 2006 and July 2014. The patients comprised three groups: LDA-interrupted group (13 patients with 13 colorectal tumors), LDA-continued group (28 patients with 31 colorectal tumors), and no anticoagulant/antiplatelet group (541 patients with 565 colorectal tumors). RESULTS: The en bloc resection rate was 100% (13/13) in the LDA-interrupted group and 90.3% (28/31) in the LDA-continued group. Incidences of poor bleeding control during the procedure and bleeding after the procedure were 7.7% (1/13) and 15.4% (2/13) of patients, respectively, in the LDA-interrupted group, and 3.2% (1/31) and 16.1% (5/31) of patients, respectively, in the LDA-continued group. No patients experienced ischemic events in the perioperative period. CONCLUSIONS: Our data suggest that continued use of LDA increased the risk of bleeding after ESD for colorectal tumors compared with nonuse of anticoagulant/antiplatelets. No significant difference was seen between the LDA-continued group and the LDA-interrupted group.

Early squamous cell carcinoma of the anal canal resected by endoscopic submucosal dissection.

The standard treatment approach for squamous cell carcinoma (SCC) of the anal canal includes abdominoperineal resection and chemoradiotherapy. However, there are currently very few reports of early SCC of the anal canal resected by endoscopic submucosal dissection (ESD). We report 2 rare cases of SCC of the anal canal resected by ESD. In case 1, a 66-year-old woman underwent a colonoscopy due to blood in her stool, and an elevated lesion, 15 mm in size, was identified from the rectum to the dentate line of the anal canal on internal hemorrhoids. The lesion was diagnosed as an early SCC of the anal canal, and ESD was successfully performed. The histopathological diagnosis was SCC in situ. In case 2, a 71-year-old woman underwent a colonoscopy due to constipation, and an elevated lesion, 25 mm in size, was identified from the dentate line to the anal canal. The lesion was diagnosed as early-stage SCC of the anal canal, and ESD was successfully performed. The histopathological diagnosis was SCC in situ. No complications or recurrence after ESD occurred in either case.

Is it possible to discriminate between neoplastic and nonneoplastic lesions in ulcerative colitis by magnifying colonoscopy?

BACKGROUND: Colitis-associated cancer/dysplasia is an intestinal tract condition that can affect the life expectancy of patients with ulcerative colitis. It is often difficult to detect neoplastic lesions. This study evaluated whether any endoscopic features are effective for distinguishing colitis-associated cancer/dysplasia from nonneoplastic lesions in patients with ulcerative colitis. METHODS: The study involved 52 patients with 61 lesions treated at Hiroshima University Hospital between September 1999 and May 2012: 10 patients with 11 dysplastic lesions, 5 patients with 5 intramucosal carcinomas, 3 patients with 3 submucosal carcinomas, and 34 patients with 42 nonneoplastic lesions. All patients had undergone targeted biopsy. Endoscopic findings were compared between patients with biopsy-determined neoplasia and those with biopsy-determined nonneoplasia. Multivariate regression analysis was performed to identify magnifying chromocolonoscopy features predictive of neoplasia. RESULTS: No significant difference was found in conventional endoscopy features between the neoplastic and nonneoplastic lesions. Under magnifying chromocolonoscopy, the pit density of the neoplastic lesions was found to be significantly greater than that of the nonneoplastic lesions (89% [17/19] versus 60% [25/42], respectively). Pit margins were more frequently irregular in the neoplastic lesions than in the nonneoplastic lesions (63% [12/19] versus 33% [14/42], respectively). CONCLUSIONS: In differentiating between colitis-associated neoplastic and nonneoplastic lesions, focus should be on the high residual density of pits and irregular pit margins observed under magnifying chromocolonoscopy.