Prediction of technically difficult, colorectal, endoscopic submucosal dissection: Is the procedural time a good endpoint?

Abstract

metaplasia (CEIM), and excluding patients in whom recurrent dysplasia developed within 18 months. These analyses produced results highly similar to those of the main analyses.Debnath and Rathi 2 raised several questions and points that we wish to clarify. In our analyses, we did not exclude patients in whom endoscopically visible dysplastic lesions developed, as noted above. We did exclude patients with endoscopic evidence of recurrent Barrett's esophagus from the analyses of dysplasia recurrence. There is general consensus that recurrent Barrett's esophagus, with or without associated dysplasia, likely represents a lesion at high risk for progression to esophageal adenocarcinoma, and repeated ablation or resection is warranted for these patients. Debnath and Rathi 2 also noted that prior studies found that pretreatment high-grade dysplasia/intramucosal carcinoma was an independent risk factor for dysplasia recurrence. In our analyses, high-grade dysplasia/intramucosal carcinoma was associated with a nonsignificant, but nearly 2-fold, increased risk of recurrence (aHR 1.92; 95% CI, 0.75-4.92); this point estimate is similar to that reported in prior studies. Finally, there was concern that the definition of CEIM was not uniform. We did in fact use a uniform definition to define CEIM (a single negative EGD result). We also performed sensitivity analyses redefining CEIM as 2 negative EGD results, and the results were qualitatively unchanged.We agree with Verheij et al 1 that our analyses could support the notion that recurrent GEJIM does not represent an increased risk of progression to dysplasia or esophageal adenocarcinoma and that endoscopic retreatment of recurrent GEJIM may not be indicated. Given the observational nature of our study, these findings should be confirmed by independent studies. Furthermore, careful visual inspection of the GEJ/cardia is indisputably critical to identify visible recurrent dysplastic lesions. However, in our cohort several dysplasia recurrences were detected by analysis of random biopsy specimens, and thus we believe that there remains a benefit to random sampling at the GEJ during postablation surveillance in patients who have achieved CEIM.

Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers

“…Besides, tumor location was also omitted from the final cESD-TIME formula after backward selection, suggesting that the influence of this factor on ESD duration was limited. This was unexpected because anatomical location, in general, is closely correlated with endoscopic maneuverability, a crucial determinant of ESD difficulty [7,26]. However, a recent editorial has already pointed out that performing ESD in certain situations (e. g. patients with severe abdominal adhesions or a long and flexible colon) is always difficult, regardless of tumor location [7].…”

“…Although achieving 100% accuracy is probably utopian 29 , as we can learn from prediction modeling studies for surgical procedure times (highest R 2 values around 80% 30 31 32 33 34 ), we acknowledge that there is still room for improvement. As proposed by several ESD experts 7 26 , endoscopic maneuverability could be key to increasing the predictive performance. This is substantiated by a Japanese study 27 and our finding that maneuverability (as subjectively evaluated during the ESD) was a significant predictor of procedure duration ( Supplementary Results ).…”

“…Lastly, no traction device-assisted ESD techniques were used in our cohort. This is relevant because these techniques may markedly change the nature of a procedure 26 , and thereby also the factors determining ESD duration. Therefore, our findings may not be valid for traction device-assisted ESD procedures.…”

“…Lastly, no traction device-assisted ESD techniques were used in our cohort. This is relevant because these techniques may markedly change the nature of a procedure [26], and thereby also the factors This article is protected by copyright. All rights reserved.…”

“…As exploratory analysis, we also included endoscopic maneuverability in the cESD-TIME formula and evaluated how the model performance would change. Maneuverability is generally referred to as the degree of having difficulty with obtaining and maintaining an optimal dissection plane through the submucosa, e. g. due to paradoxical movement of the endoscope [7,26,27]. However, there are currently no standardized criteria available for determining or classifying endoscopic maneuverability.…”