Endoscopic submucosal dissection for colorectal polyps: outcome determining factors.

BACKGROUND: Endoscopic submucosal dissection (ESD) has gained increasing popularity in the management of complicated colorectal polyps. However, clinical outcomes for ESD have remained highly inconsistent worldwide. This study investigated and analysed factors that significantly affect ESD outcomes. METHODS: We conducted a single-centred retrospective study on 220 colorectal polyps removed by ESD from 1st January 2016 to 31st December 2020. Data were collected and retrieved from clinical records. Variables studied included patient demographics, ESD technicalities and polyp characteristics. The primary outcome was completeness of resection based on en bloc and R0 resection rates. The secondary outcomes were recurrence, complications and hospital stay. Further analysis was performed for significant outcome determining factors. RESULTS: The en bloc resection and R0 resection rates were 97.3% and 65% respectively. Intraprocedural and delayed perforation rates were 3.2% and 0.5% respectively. Intraprocedural and delayed bleeding rates were both 1.8%. Post-polypectomy syndrome rate was 2.7%. The median hospital stay was 4 days. Submucosal fibrosis was a significant determining factor for lower en bloc resection (p = 0.004), lower R0 resection (p = 0.002), intraprocedural perforation (p = 0.001), intraprocedural bleeding (p = 0.025) and post-polypectomy syndrome (p = 0.039). Hybrid snaring was associated with lower en bloc resection (p < 0.001), while longer ESD time was associated with lower R0 resection (p = 0.003) and post-polypectomy syndrome (p = 0.025). Other significant factors for post-polypectomy syndrome included young age (p = 0.021) and large polyp size (p = 0.018). Secondary analysis showed that submucosal fibrosis was significantly associated with non-granular lesions (p < 0.001) and prior biopsy (p = 0.003). CONCLUSION: Submucosal fibrosis, hybrid snaring, ESD time, age and polyp size were significant outcome determining factors for ESD. By identifying these factors, strategies may be formulated to improve ESD outcomes.

Predictors of morbidity related to stoma closure after colorectal cancer surgery.

PURPOSE: A defunctioning stoma is essential in reducing symptomatic leakage after colorectal surgery, particularly after lower anterior resection. Subsequent stoma closure is associated with morbidity and rarely mortality. This study aimed to identify the risk factors associated with post-operative complications related to stoma closure. METHODS: This retrospective cohort included patients who have undergone elective stoma closure between 2015 and 2017. Patient demographics, pre-morbidities, use of systemic therapy, stoma characteristics, and post-operative complications were retrieved from electronic records. Univariate and multivariate analysis was carried out to identify risk factors of stoma closure related morbidity. RESULTS: Ninety patients were included with a median age of 65 years, of which 58 (64.4%) of them were male. Sixty-nine (76.7%) patients had loop colostomy, while the rest had loop ileostomy. Fifty-four (60%) patients received neoadjuvant or adjuvant therapy. The median time interval from stoma creation to closure was 15 months. Nineteen (21.1%) patients had post-operative complications. The two most commonly observed post-operative complications were wound complications (16.7%) and intra-abdominal collections (6.7%). Fifteen (16.7%) patients developed an incisional hernia. The median follow-up time was 29 months. There was no 30-day mortality in this cohort. In multivariate analysis, adjuvant chemotherapy was associated with a higher risk of wound complications (p = 0.027). Higher risk of incisional hernia was seen in patients with history of hypertension (p = 0.046), use of adjuvant chemotherapy (p = 0.042) and stoma-related complications before closure (p = 0.002). Male patients might be associated with a higher risk of incisional hernia. CONCLUSION: Adjuvant chemotherapy is associated with a higher risk of post-operative complications, particularly with wound complications. Male patients, hypertension, adjuvant chemotherapy, and stoma-related complications are associated with a higher risk of incisional hernia.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect.

BACKGROUND: Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS: We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS: A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS: Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Use of intravenous iron therapy in colorectal cancer patient with iron deficiency anemia: a propensity-score matched study.

PURPOSE: Iron deficiency anemia is common in colorectal cancer patients and is related to poor surgical outcome. Increasing evidence supports preoperative use of intravenous iron (IVI) to correct anemia. Our study investigates effect of preoperative IVI on hemoglobin level. METHODS: From August 2017 to March 2019, colorectal cancer patients with iron deficiency anemia received intravenous iron at least 2 weeks before their scheduled operations (IVI group). These patients' prospectively collected data were compared to a historic cohort of anemic patients who received elective colorectal surgery within 3 years before the study period (non-IVI). RESULTS: Forty-six patients were included after receiving intravenous iron. After propensity score matching on 1:2 ratio, 38 patients in IVI group were matched with 62 patients from non-IVI group. There was no statistical difference for preoperative mean hemoglobin level between the two groups (8.43 g/dL in IVI, 8.79 g/dL in non-IVI, p = 0.117), but IVI group has significantly higher mean hemoglobin level on admission (10.63 g/dL in IVI, 9.46 g/dL in non-IVI, p = < 0.001). IVI group had higher median hemoglobin rise (1.9 in IVI, 0.6 in non-IVI, p = <0.001) and significantly less red cell transfusion (8 patients in IVI, 30 in non-IVI, p = 0.006). Subgroup analysis showed that less patients in IVI group required transfusions in preoperative period (1 in IVI group, 20 in non-IVI, p < 0.001). CONCLUSION: Our data suggested that IVI can significantly increase hemoglobin level in iron deficiency anemic patients before colorectal surgery, with reduction in red cell transfusions.

Case-Matched Analysis Comparing Endoscopic Submucosal Dissection and Surgical Removal of Difficult Colorectal Polyps.

INTRODUCTION: It is not uncommon to encounter colorectal polyps which could not be removed easily by simple polypectomy. Endoscopic submucosal dissection (ESD) has been a well-established method for doing so. We compared the result between ESD and surgical removal of these difficult colorectal polyps. MATERIALS AND METHOD: During the period between January 2013 and December 2016, patients who have failed endoscopic removal of colorectal polyp requiring second treatment, either by ESD or surgical removal, were matched into two groups and reviewed. Outcomes between two groups of patients, including complication rate, reintervention rate, length of stay, and readmission rate were studied. RESULT: A statistically significant difference in mean length of stay was observed. The length of stay was 4.2 days for ESD group and 8.7 days for surgery group (P < .001). There was significantly less than 30-day readmission in ESD group as well (0% versus 7.6%, P = .001). A higher complication rate was observed in surgery group (0% versus 18.4%, P < .001). CONCLUSION: ESD is a good method to remove colorectal polyps that are not suitable for endoscopic mucosal resection. When compared with traditional surgery, ESD had the benefit of shortening hospital stay and less postprocedure complication.