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Background Clinically significant delayed bleeding (CSDB) is a frequent, and sometimes severe, adverse event after colorectal endoscopic submucosal dissection (ESD). We evaluated risk factors of CSDB after colorectal ESD. Methods We analyzed a prospective registry of 940 colorectal ESDs performed from 2013 to 2022. The incidence of bleeding was evaluated up to 30 days. Risk factors for delayed bleeding were evaluated by multivariate logistic regression. A Korean scoring model was tested, and a new risk-scoring model was developed and internally validated. Results CSDB occurred in 75 patients (8.0%). The Korean score performed poorly in our cohort, with a receiver operating characteristic (ROC) curve of 0.567. In the multivariate analysis, risk factors were age ≥75 years (odds ratio [OR] 1.63; 95%CI 0.97–2.73; 1 point), use of antithrombotics (OR 1.72; 95%CI 1.01–2.94; 1 point), rectal location (OR 1.51; 95%CI 0.92–2.48; 1 point), size >50 mm (OR 3.67; 95%CI 2.02–7.14; 3 points), and American Society of Anesthesiologists (ASA) score of III or IV (OR 2.26; 95%CI 1.32–3.92; 2 points). The model showed fair calibration and good discrimination, with an area under the ROC curve of 0.751 (95%CI 0.690–0.812). The score was used to define two groups of patients, those with low–medium risk (0 to 4 points) and high risk (5 to 8 points) for CSDB (respective bleeding rates 4.1% and 17.5%). Conclusion A score based on five simple and meaningful variables was predictive of CSDB. [ABSTRACT FROM AUTHOR]

Large flat colorectal polyps are often encountered during screening colonoscopies. The most frequently used approach for resecting these polyps is endoscopic mucosal resection, which is associated with a substantial rate of recurrent or residual adenoma, necessitating routine follow-up colonoscopy within months. An alternative endoscopic resection technique, endoscopic submucosal dissection, may enable en bloc resection of such polyps, potentially reducing the rate of recurrent or residual adenoma. This randomized controlled trial compared these 2 endoscopic resection techniques in terms of the rate of neoplastic local recurrence during the 6-month follow-up colonoscopy. Visual Abstract. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas: Large flat colorectal polyps are often encountered during screening colonoscopies. The most frequently used approach for resecting these polyps is endoscopic mucosal resection, which is associated with a substantial rate of recurrent or residual adenoma, necessitating routine follow-up colonoscopy within months. An alternative endoscopic resection technique, endoscopic submucosal dissection, may enable en bloc resection of such polyps, potentially reducing the rate of recurrent or residual adenoma. This randomized controlled trial compared these 2 endoscopic resection techniques in terms of the rate of neoplastic local recurrence during the 6-month follow-up colonoscopy. Background: Endoscopic resection of adenomas prevents colorectal cancer, but the optimal technique for larger lesions is controversial. Piecemeal endoscopic mucosal resection (EMR) has a low adverse event (AE) rate but a variable recurrence rate necessitating early follow-up. Endoscopic submucosal dissection (ESD) can reduce recurrence but may increase AEs. Objective: To compare ESD and EMR for large colonic adenomas. Design: Participant-masked, parallel-group, superiority, randomized controlled trial. (ClinicalTrials.gov: NCT03962868) Setting: Multicenter study involving 6 French referral centers from November 2019 to February 2021. Participants: Patients with large (≥25 mm) benign colonic lesions referred for resection. Intervention: The patients were randomly assigned by computer 1:1 (stratification by lesion location and center) to ESD or EMR. Measurements: The primary end point was 6-month local recurrence (neoplastic tissue on endoscopic assessment and scar biopsy). The secondary end points were technical failure, en bloc R0 resection, and cumulative AEs. Results: In total, 360 patients were randomly assigned to ESD (n  = 178) or EMR (n  = 182). In the primary analysis set (n  = 318 lesions in 318 patients), recurrence occurred after 1 of 161 ESDs (0.6%) and 8 of 157 EMRs (5.1%) (relative risk, 0.12 [95% CI, 0.01 to 0.96]). No recurrence occurred in R0-resected cases (90%) after ESD. The AEs occurred more often after ESD than EMR (35.6% vs. 24.5%, respectively; relative risk, 1.4 [CI, 1.0 to 2.0]). Limitation: Procedures were performed under general anesthesia during hospitalization in accordance with the French health system. Conclusion: Compared with EMR, ESD reduces the 6-month recurrence rate, obviating the need for systematic early follow-up colonoscopy at the cost of more AEs. Primary Funding Source: French Ministry of Health. [ABSTRACT FROM AUTHOR]

Background and Aim: Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. Patients and Methods: Prospective data (Jan 2016–May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5 min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post‐therapy. Results: Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8–14) and median complete Rockall score (RS) was 7 (IQR: 6–8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314 = 53%) and Forrest Ib the most common bleed type in PUD (100/167 = 60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven‐day and 30‐day all‐cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. Conclusions: These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates. [ABSTRACT FROM AUTHOR]

Référence: Pohl H, Grimm IS, Moyer MT, et al. Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial. Gastroenterology. 2019 Mar 15. Pii : S0016-5085(19)33573-5. Doi : 10.1053/j.gastro.2019.03.019. [Epub ahead of print] [ABSTRACT FROM AUTHOR]

Résumé: Les techniques de résection endoscopique représentent l'exemple le plus caractéristique du basculement de l'endoscopie d'un champ diagnostique vers un champ thérapeutique. La polypectomie, la mucosectomie et la dissection sous-muqueuse ont désormais une place bien définie dépendant du type de lésion et du risque de dégénérescence pouvant être prédit à l'aide des techniques de chromoendoscopie dont la maîtrise est un prérequis indispensable avant de se lancer dans ces procédures thérapeutiques. Toutes ces techniques de résection endoscopique ont une efficacité carcinologique comparable à la chirurgie lorsque les critères de curabilité anatomopathologique sont respectés. La morbidité très inférieure de ces gestes endoscopiques par rapport à leur alternative chirurgicale doit imposer une prise en charge endoscopique première de ces lésions. Une formation des personnels médicaux et paramédicaux et un matériel adapté sont nécessaires dans les structures réalisant le dépistage du cancer du côlon pour améliorer la prise en charge des patients et diminuer l'incidence et la mortalité du cancer du côlon. Les progrès des méthodes diagnostiques et des traitements oncologiques pourraient étendre encore le champ des techniques de résection endoscopique pour les tumeurs superficielles du tube digestif. Endoscopic resection techniques represent the most characteristic example of the switch from endoscopy of a diagnostic field to a therapeutic field. Polypectomy, Endoscopic mucosal resection and endoscopic submucosal dissection have now a definite place depending on the type of lesion and the risk of cancer that can be predicted using chromoendoscopy techniques whose mastery is a prerequisite before performing this skilled procedures. All these techniques of endoscopic resection have a carcinologic efficacy comparable to surgery when the curability criteria are respected. The very inferior morbidity of these endoscopic procedures compared to their surgical alternative must impose a first endoscopic management of these lesions. Training of medical and paramedical staff and appropriate equipment are required in facilities performing colon cancer screening to improve patient management and reduce the incidence and mortality of colon cancer. Advances in diagnostic methods and oncological treatments may further extend the field of endoscopic resection techniques for superficial tumors of the digestive tract. [ABSTRACT FROM AUTHOR]

Countertraction using the DCT technique enabled us to identify a good submucosal dissection plane, even in the diverticulum area. 2 Endoscopic submucosal dissection of the lesion. a The double-clip traction technique was used. b Small incisions were made in the normal mucosa to help clip closure of the scar. c Closure of the scar. [Extracted from the article]

Introduction: The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort., Methods: Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed., Results: Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers., Discussion: Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts., (Copyright © 2024 by The American College of Gastroenterology.)

Background: EUS-guided choledoco-duodenostomy using electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) is becoming the gold standard in case of endoscopic retrograde cholangio-pancreatography failure for distal malignant obstruction. Long-term data in larger samples are lacking., Methods: This was a prospective monocentric study including all patients who underwent EUS-guided choledochoduodenostomy (CDS) between September 2016 and December 2021. The primary endpoint was the rate of biliary obstruction during follow-up. Secondary endpoints were technical and clinical success rates, adverse event rates, and identification of risk factors for biliary obstruction., Results: One hundred and twenty-three EUS-guided CDS using ECE-LAMS were performed at Limoges University Hospital were performed during the study period and included in the study. The main cause of obstruction was pancreatic adenocarcinoma in 91 (74.5%) cases. The technical and clinical success rates were 97.5% and 91%, respectively. Twenty patients (16.3%) suffered from biliary obstructions during a mean follow-up of 242 days. The clinical success rate for endoscopic desobstruction was 80% (16/20). In uni- and multivariate analyses, only the presence of a duodenal stent (odds ratio [OR]: 3.6, 95% confidence interval [CI] 95%: 1.2-10.2; P = 0.018) and a bile duct thinner than 15 mm (OR: 3.9, CI 95%: 1.3-11.7; P = 0.015) were the significant risk factors for biliary obstruction during the follow-up., Conclusion: Obstruction of LAMS occurred in 16.3% of cases during follow-up and endoscopic desobstruction is efficacious in 80% of cases. The presence of duodenal stent and a bile duct thinner than 15 mm are the risk factors of obstruction. Except in these situation, EUS-CDS with ECE-LAMS could be proposed in the first intent in case of distal malignant obstruction., Competing Interests: None