Background:Advances in colorectal cancer (CRC) screening and endoscopic techniques have led to increased detection of T1 CRC. Patient management relies on histopathological criteria predicting lymph node metastasis (LNM), including submucosal invasion depth (SID) >1000 µm. However, the independent prognostic value of isolated deep invasion remains unclear. Methods:We performed a retrospective multicenter study of patients treated at 18 European centers between 2009 and 2022. Patients with T1 CRC endoscopically resected en bloc and with isolated SID >1000 µm (without other high-risk features) were included. Two groups were analyzed: patients who underwent additional surgery and those who were followed with surveillance. Rates of LNM (surgery group) and recurrence (local and distant; surveillance group) were assessed. Exploratory multivariable analyses were performed to evaluate clinicopathological factors associated with LNM. Results:Among 179 included patients (124 surgery, 55 surveillance), LNM was found in 16/124 surgical specimens (12.9%; 95%CI 7.7-20.4) and recurrence occurred in 2/55 patients undergoing surveillance (3.6%; 95%CI 0.4-12.6). LNM occurred in 1/50 patients (2.0%) with SID <2000 µm and in 15/74 patients (20.3%) with SID ≥2000 µm. Multivariable analysis revealed SID ≥2000 µm (odds ratio [OR] 3.59; 95%CI 1.14-13.71) and colonic (vs. rectal) tumor location (OR 3.63; 95%CI 1.07-16.77) as factors associated with LNM. Conclusion:Isolated deep submucosal invasion in T1 CRC was associated with a non-negligible rate of LNM in this real-world cohort. In exploratory analyses, SID ≥2000 µm was associated with LNM.

BACKGROUND & AIMS:For the local excision of early rectal tumors (ERTs), the relative effectiveness of endoscopic submucosal dissection (ESD) vs transanal endoscopic microsurgery (TEM) is subject to debate. The comparisons are limited to retrospective, single-center studies lacking a health economic assessment. METHODS:A cost-effectiveness analysis was conducted alongside a nonrandomized, 2-arm, comparative, multicenter study. The main inclusion criterion was an ERT (adenomas, in situ and usT1N0 carcinomas) that could be resected with ESD or TEM, depending on the center. The primary effectiveness criterion was complete resection. A health care system perspective and a 1-year horizon were adopted for the cost evaluation. The results of the analysis were adjusted for baseline covariates: age, sex, body mass index, American Society of Anesthesiologists score, histology, and previous pelvic surgery. RESULTS:A total of 213 ESD and 117 TEM procedures were analyzed. At 1 year and with a willingness to pay of €2500 for complete resection, the incremental net monetary benefit of ESD was significant (€1797; 95% confidence interval, €861-€3,032; P < .001). ESD was more cost-effective for decision thresholds ranging from €0 to €6000. In terms of secondary outcomes, the en bloc excision rate favored ESD (99.0% vs 92.5%, P < .01). There were no significant between-group differences in overall and major morbidity. At 3 years, a cost-utility analysis did not reveal between-group differences in health-related quality of life, and the overall survival rates were similar. However, the disease-free survival rate was higher after ESD (94.3% vs 84.6% for TEM; adjusted hazard ratio, 3.55; 95% confidence interval, 1.64-7.75; P < .001). CONCLUSIONS:For ERT, ESD was more cost-effective and offered higher-quality excision and lower recurrence rates than TEM. (ClinicalTrials.gov, Number: NCT02885142).

BACKGROUND : Endoscopic submucosal dissection (ESD) offers better oncological outcomes and lower recurrence rates, but is limited in colorectal use owing to concerns about adverse events, especially perforation. This study aimed to explore the clinical burden and risk factors for perforation in a Western cohort. METHODS : Analysis of intraprocedural and delayed perforations from a prospective cohort study including 3770 colorectal ESDs performed at one Belgian and 12 French centers between September 2019 and September 2022. RESULTS:  Intraprocedural perforation (n = 314; 8.3 %) or delayed perforation (n = 22; 0.6 %) occurred in 336/3770 procedures (8.9 %). Conservative management was effective for 308/336 perforations (91.7 %), especially for intraprocedural perforations (n = 304 /314; 96.8 %). Delayed perforation frequently required emergent surgery (n = 18/22; 81.8 %). Multivariable analysis identified factors associated with intraprocedural perforation, including previous resection (odds ratio [OR] 1.9, 95%CI 1.3 to 2.7), lesion size ≥ 50 mm (OR 1.5, 95%CI 1.2 to 1.9), poor maneuvrability (OR 2.0, 95%CI 1.4 to 2.5) and severe fibrosis (OR 4.4, 95%CI 3.2 to 6.1). Proximal colonic location and severe fibrosis were associated with increased risk of delayed perforation. A perforation ≥ 5 mm (OR 8.9, 95 %CI 1.0 to 76.5) and fever (OR 9.5, 95 %CI 2.4 to 38.0) or abdominal pain (OR 26.6, 95 %CI 3.3 to 213.8) were associated with surgery after intraprocedural perforation (univariable analysis). No deaths were directly linked to perforation, but one death occurred due to delayed bleeding. CONCLUSIONS:  ESD-related perforations are often manageable conservatively, with surgery being rare; however, delayed perforations remain challenging and often require surgery. Patients should be informed of both the benefits and risks.

Background Endoscopic submucosal dissection (ESD) allows for en bloc endoscopic resection of T1 esophageal adenocarcinoma arising on Barrett's esophagus (BE). Although the safety of the procedure is well established, the oncological adequacy of the procedure and the long-term follow up of the patients have not been prospectively studied. Methods We conducted a prospective, multicenter study involving 9 French and Belgian centers. We included patients treated with ESD for a visible endoscopic lesion of more than 15mm documented with dysplasia, with a 3-year follow up. The primary endpoint was the histologically complete resection rate for adenocarcinoma and high-grade dysplasia (HGD). Results A total of 141 patients were included in the study between December 2016 and January 2019. The R0 resection rate was 85% for adenocarcinoma and HGD, and 81% for invasive adenocarcinoma. The complication rate was 17%, of which 5% were early complications and 12% were late complications, mainly esophageal strictures. During a median follow-up length of 36.3 months, recurrence was observed in 15% of the patients and was endoscopically manageable in 44%. Eight patients (6%) underwent esophagectomy for a high-risk adenocarcinoma. Overall, 14 patients (12%) died during follow up, 3 of them (2.5%) from esophageal adenocarcinoma. Conclusion Endoscopic resection by ESD is a safe and effective technique to treat T1 esophageal adenocarcinoma, allowing avoidance of esophagectomy in 94% of the patients.

Aim: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the two main techniques used for endoscopic resection of superficial rectal tumours. The aim of this study was to compare the outcomes of ESD and EMR in treating superficial rectal tumours. Method: A retrospective observational study was conducted at two French centres including all patients treated with ESD or EMR for superficial rectal tumours. The primary outcome was the rate of local recurrence at the first follow-up endoscopy after endoscopic resection. Secondary outcomes included the curative resection rate, procedure duration, length of hospital stay, complication rates and the need for additional surgery. Results: A total of 254 patients were included, 159 treated with ESD and 95 treated with EMR. The local recurrence rate at the first follow-up endoscopy was 8.6% and was significantly lower in the ESD group than in the EMR group (4.3% vs. 16.9%; p = 0.005). The rates of en bloc and histologically complete resections were higher in the ESD group (88.1% vs. 42.7% and 85.5% vs. 38.9%, respectively; p < 0.001), while the curative resection rate was 90.6% in the EMR group and 92.5% in the ESD group (p = 0.59). Mostly due to poor histoprognostical criteria, 6.0% of patients underwent additional surgery (6.3% vs. 5.2% in the ESD vs. EMR group, respectively; p = 0.73). Conclusion: ESD demonstrated higher rates of en bloc, R0 resection than EMR, translating into significantly lower rates of local recurrence at the first follow-up endoscopy.

BACKGROUND AND AIMS:New techniques for endoscopic resection, including endoscopic submucosal dissection (ESD), have been developed to allow for en-bloc resection with very low recurrence rates and organ sparing in patients without inflammatory bowel disease (IBD). Data on ESD for the management of colorectal dysplasia in IBD patients are scarce. We aimed to evaluate the efficacy and safety of ESD for the treatment of IBD. METHODS:We conducted a retrospective multicenter cohort study that evaluated consecutive ESD procedures in IBD patients with visible dysplasia from 20 French centers with ESD experience. Between June 2008 and March 2022, all IBD patients included in the local ESD databases and who underwent ESD for visible dysplasia proven on biopsy were included. All patients were included from the date ESD was performed, and endoscopic follow-up and surgical data were collected. RESULTS:Among the 88 lesions resected in 82 patients (19 patients with Crohn's disease), 82% and 80% of patients had R0 and curative resection, respectively. Ten (12%) patients required surgery: 1 for complication, 3 for endoscopic failure, and 6 for noncurative resection. After a median follow-up of 20 (IQR 10.5-45) months, 4 patients experienced local recurrence, and 14 (17%) underwent surgery. Two patients died from cardiovascular issues during the follow-up. Factors associated with local recurrence were R1 resection, associated primary sclerosing cholangitis, a personal history of colorectal cancer, and active lesions at the ESD site. CONCLUSIONS:Endoscopic submucosal dissection is feasible for IBD patients with visible colorectal dysplasia and has an acceptable safety profile. These findings should be evaluated further in control trials.

BACKGROUND:For large non-pedunculated rectal polyps, en bloc resection via endoscopic submucosal dissection (ESD) is typically recommended due to presumed higher risk of submucosal invasive cancer (SMIC) compared with the colon; however, data on cancer risk by location remain controversial. OBJECTIVE:Using the French ESD registry, we compared SMIC rates in large non-pedunculated colorectal polyps in the rectum versus colon. Procedural outcomes were also compared. DESIGN:From September 2019 to September 2022, all large non-pedunculated polyps resected by ESD in 13 centres were included. Oncological and procedural outcomes were analysed using propensity score matching (PSM) and inverse probability weighting, accounting for relevant influencing factors. A subgroup analysis was performed on cases from the three largest centres, where such polyps were exclusively treated with ESD. RESULTS:Among 3770 lesions, 3310 were analysed. Rectal lesions were larger (56.0 (40; 75) mm vs 47.0 (37; 62) mm), more often granular (80.0% vs 59.4%) and mixed nodular (54.0% vs 32.5%) (p<0.001). After PSM, submucosal cancer rates were not significantly different between rectal and colonic lesions of similar size and morphology (9.8% vs 8.9%, p=0.52). En bloc (97.7% vs 97.3%, p=0.757) and R0 resection rates (89.7% vs 89.5%, p=0.937) were also comparable. Perforation (5.5% vs 7.9%, p=0.057) and surgery for complications (0.1% vs 1.1%, p=0.051) showed a non-significant trend towards higher rates in colonic procedures. Subgroup analysis from the three centres exclusively performing ESD for large non-pedunculated polyps confirmed these findings. CONCLUSION:In our multicentre registry, large non-pedunculated polyps do not show a higher prevalence of SMIC in the rectum compared with colon, when adjusted for relevant factors such as size and morphology. Therefore, risk features, rather than location, should guide the choice of resection technique. Technical outcomes were comparable between rectal and colonic ESD, with a trend for higher complication rates in the colon. TRIAL REGISTRATION NUMBER:NCT04592003.

New techniques for endoscopic resection, including endoscopic submucosal dissection (ESD), have been developed to allow for en-bloc resection with very low recurrence rates and organ sparing in patients without inflammatory bowel disease (IBD). Data on ESD for the management of colorectal dysplasia in IBD patients are scarce. We aimed to evaluate the efficacy and safety of ESD for the treatment of IBD. We conducted a retrospective multicenter cohort study that evaluated consecutive ESD procedures in IBD patients with visible dysplasia from 20 French centers with ESD experience. Between June 2008 and March 2022, all IBD patients included in the local ESD databases and who underwent ESD for visible dysplasia proven on biopsy were included. All patients were included from the date ESD was performed, and endoscopic follow-up and surgical data were collected. Among the 88 lesions resected in 82 patients (19 patients with Crohn's disease), 82% and 80% of patients had R0 and curative resection, respectively. Ten (12%) patients required surgery: 1 for complication, 3 for endoscopic failure, and 6 for noncurative resection. After a median follow-up of 20 (IQR 10.5-45) months, 4 patients experienced local recurrence, and 14 (17%) underwent surgery. Two patients died from cardiovascular issues during the follow-up. Factors associated with local recurrence were R1 resection, associated primary sclerosing cholangitis, a personal history of colorectal cancer, and active lesions at the ESD site. Endoscopic submucosal dissection is feasible for IBD patients with visible colorectal dysplasia and has an acceptable safety profile. These findings should be evaluated further in control trials.

BACKGROUND:Gastric adenoma is widely acknowledged as a premalignant lesion that can progress to gastric adenocarcinoma. The distinctions among subtypes of gastric adenomas have been infrequently explored in existing literature. AIM:To assess the subtype-specific risk factors and outcomes of endoscopic resection (ER) for gastric adenomas. METHODS:This is a retrospective cohort study. Among 162 patients who underwent ER for gastric lesions larger than 10 mm between 2017 and 2022, 79 patients with gastric adenomas were included. Hyperplastic polyps (n = 37) and subepithelial lesions (n = 46) were excluded. Logistic regression and survival analyses were conducted. RESULTS:The 79 patients (mean age 68.1 years; 65% male) had adenoma subtypes: 62% intestinal, 29% foveolar, 8% pyloric, and 1% oxyntic. The mean follow-up was 26 months. Intestinal adenoma was strongly linked to a family history of gastric adenocarcinoma and atrophic gastritis (P < 0.001); foveolar adenoma was significantly associated with intestinal metaplasia (P < 0.001). Pyloric adenomas had the largest polyp size (P < 0.001). Recurrence rates were 8%, 17%, and 17% for the respective subtypes (P = 0.07), with no significant difference in the meantime to recurrence (P = 0.8). Independent predictors of recurrence after ER included a family history of gastric adenocarcinoma, active Helicobacter pylori infection, polyp size ≥ 30 mm, presence of > 3 polyps and Paris 0-IIc morphology (P < 0.001). CONCLUSION:This study identifies distinct risk factor profiles for different subtypes of gastric adenomas and independent recurrence predictors post-ER, underscoring the importance of subtype-specific tailored risk assessment and surveillance strategies.

BACKGROUND AND AIMS:Endoscopy makes a significant contribution to the carbon footprint of healthcare. A randomized trial (RESECT-COLON) demonstrated that endoscopic submucosal dissection (ESD) decreases the recurrence rate of large adenomas (>25 mm) vs piecemeal endoscopic mucosal resection (P-EMR), reducing the need for follow-up colonoscopy. We aimed to compare the carbon footprint of those 2 strategies. METHODS:Devices used for both procedures were collected prospectively for each of the 359 patients. P-EMR and ESD were assessed using the life cycle assessment, evaluating 4 parameters: endoscopes and disposable medical products, electricity consumption, anesthetic products, and patient transport. The carbon footprint of the follow-up was simulated in both arms with different scenarios. We performed a post hoc analysis of the carbon footprint of these 2 strategies over 18 months. RESULTS:Carbon footprint of a single P-EMR procedure was 63.5 kg carbon dioxide equivalent (CO2e) vs 73.2 kg CO2e for ESD (half for patient transport). Including follow-up in local centers, P-EMR generates 93.5 kg CO2e and ESD 76.3 kg CO2e, corresponding to an absolute reduction of 17 kg CO2e (18%) per procedure for ESD. Simulating a strategy of P-EMR resection and follow-up both performed in local centers, the global impact with 18 months follow-up would be 67.3 kg CO2e, favoring P-EMR over ESD. CONCLUSIONS:ESD strategy for lesions over 25 mm could reduce the environmental impact by reducing the associated follow-up colonoscopies and transports of patients. If P-EMR could be performed in local centers with similar quality, results would be in favor of local P-EMR.

We read with interest the paper from Akira Ouchi et al1 on behalf of the study group for the JSCCR-T. This study is important since the JSCCR criteria for additional surgical resection after local excision of a T1 colorectal cancer (CRC) are used in many countries. We recently published a study comparing the impact of surgery after endoscopic resection (endoscopic mucosal resection or endoscopic submucosal dissection) in high-risk patients with histological risk factors, also using a propensity score matching method.2 Our results, obtained in a Western country with the involvement of expert endoscopists and pathologists, are similar to those of Ouchi et al, with a very low rate of local and distant recurrence. These studies demonstrate that the JSCCR histological criteria, used in both works, have a very low sensitivity to predict lymph node invasion and the usefulness of surgery in this situation. We think that a different approach should be used before considering additional surgery. The first point to consider is the association of each JSCCR criterion with its risk of lymph node metastases.3 It is now well demonstrated that the depth of submucosal invasion is not a risk factor for lymph node invasion, with a very low reproducibility of measurement.4 Indeed, this parameter had been chosen by Japanese pathologists to compensate for the low reproducibility of qualitative parameters such as lymphovascular invasion, grades 2 and 3 budding, and the presence of poorly differentiated/signet cell/mucinous adenocarcinoma. The "positive vertical margin" parameter has also been debated since its definition varied over time. In the case of R1 resection, it has been recently shown that local resection of the scar was associated with a local recurrence rate of 9%, compared to 2.2% with surgery.5 The overall survival was similar between the 2 groups since 5 out of 8 patients who presented with recurrence after local resection were operated during follow-up. It is know well admitted that the association of 2 or more qualitative parameters, or lymphovascular invasion alone, are associated with the higher risk of lymph node metastases compared to budding or poor differentiation taken separately.6 The second point to consider before additional surgery is the location of the T1 CRC. In our study, all recurrences happened in patients with tumors located in the rectum or in the sigmoid.2 A recent paper from Japan clearly showed that tumors originating from the rectum and the left colon, and more precisely the sigmoid, were associated with a high risk of lymph node metastases.7 We consider that, in case of omission of additional surgery, these patients should have a close follow-up with pelvic magnetic resonance imaging and/or computed tomography scan to detect early recurrence and offer surgery in case of local recurrence. The third point to consider is the patient's age at diagnosis. Recently, Rönnow et al8 found that, in a large series of patients operated for T1 CRC, in the absence of qualitative parameters suggesting a high risk of lymph node metastases, an age of less than 60 years was associated with a 15% risk of metastases compared to 5% for older patients. Therefore, we think that age should be taken into account as it has also been published before in a large series of patients.9 Although the nomogram described by Kajiwara et al10 did not include age, it could be useful to estimate the risk of lymph node metastases after endoscopic resection of a T1 CRC. Finally, the fourth point to assess is the microsatellite status of the tumor with microsatellite instability (MSI) found in 10% to 15% of proximal CRC and 5% of rectal carcinoma. Indeed, CRC with MSI, which are often mucinous, is associated with a lower risk of lymph node metastases.11 In conclusion, the paper published by Ouchi et al brings additional knowledge regarding the role of surgery after endoscopic resection of T1 CRC, with the aim of selecting patients who could benefit from a "watch and wait" strategy, as is has been proposed after complete remission of more advanced rectal carcinoma treated with chemotherapy and radiotherapy. Nonetheless, complex cases must be discussed in a dedicated multidisciplinary meeting on the management of superficial cancers of the digestive tract with the involvement of endoscopists, oncologists, pathologists and surgeons.12

Aims Accurate endoscopic characterization of colorectal lesions is essential for predicting histology but remains difficult. We studied the impact of a social network workgroup on the level of characterization of colorectal lesions by gastroenterologists.

Aims Despite higher en-bloc and curative resection rates, better carcinologic outcomes and lower recurrence rates, colorectal endoscopic submucosal dissection (ESD) development is limited in the West regarding the higher rate of adverse events, especially perforations, than piece-meal endoscopic mucosal resection. This study aims to analyze prevalence, risk factors and clinical outcomes of perforations following colorectal ESD.

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.