Walter Elisei

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.

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.

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.