High total Joule heat increases the risk of post-endoscopic submucosal dissection electrocoagulation syndrome after colorectal endoscopic submucosal dissection

Abstract

BACKGROUND We hypothesized that thermal damage accumulation during endoscopic submucosal dissection (ESD) causes the pathogenesis of post-ESD electrocoagulation syndrome (PECS). AIM To determine the association between Joule heat and the onset of PECS. METHODS We performed a retrospective cohort study in patients who underwent colorectal ESD from May 2013 to March 2021 in Japan. We developed a novel device that measures swift coagulation time with a sensor adjacent to the electrosurgical coagulation unit foot switch, which enabled us to calculate total Joule heat. PECS was defined as localized abdominal pain (visual analogue scale ≥ 30 mm during hospitalization or increased by ≥ 20 mm from the baseline) and fever (temperature ≥ 37.5 degrees or white blood cell count ≥ 10000 µ/L). Patients exposed to more or less than the median Joule heat value were assigned to the high and low Joule heat groups, respectively. Statistical analyses included Mann-Whitney U and chi-square tests and logistic regression and receiver operating characteristic curve (ROC) analyses. RESULTS We evaluated 151 patients. The PECS incidence was 10.6% (16/151 cases), and all patients were followed conservatively and discharged without severe complications. In multivariate analysis, high Joule heat was an independent PECS risk factor. The area under the ROC curve showing the correlation between PECS and total Joule heat was high [0.788 (95% confidence interval: 0.666-0.909)]. CONCLUSION Joule heat accumulation in the gastrointestinal wall is involved in the onset of PECS. ESD-related thermal damage to the peeled mucosal surface is probably a major component of the mechanism underlying PECS.

Injury to the muscle layer, increasing the risk of post‐colorectal endoscopic submucosal dissection electrocoagulation syndrome

“…9,11 Ochi et al reported that Joule heat accumulation within the gastrointestinal wall was involved in the onset of PECS, and ESD-related thermal damage to the mucosal peeled surface was probably a major component of the mechanism underlying PECS. 31 Injury to the muscle layer sometimes is induced by overcoagulation to the bleeding point, dissection of fibrosis, and excessive deeper dissection. For these reasons, we believe that injury to the muscle layer is closely related to thermal damage in colorectal ESD.…”

A prospective cohort study of a new electrosurgical unit for preventing colorectal post‐endoscopic submucosal dissection coagulation syndrome

“…The definition of PECS remains controversial and is a constant limitation of studies of PECS. Some studies defined PECS according to the presence of both abdominal pain and an inflammatory response, 2,4,6,11,14–17 whereas others defined PECS as the presence of either abdominal pain or an inflammatory response 3,7,18 . However, the results of our previous study indicating that the later criteria comprising the presence of either localized abdominal pain or an inflammatory response is the optimal diagnostic criteria for PECS as some patients with obvious abdominal pain or severe inflammation did not meet the former criteria for PECS 13 .…”

“…1e,f). At 1000-1600 Ω, the predicted range of human internal resistance, 11 the effective power of the maXium unit was much lower than that of the VIO300D unit. These results indicate that the maXium unit may allow effective submucosal dissection with lower power compared to the VIO3 unit, thereby reducing serosal injury during ESD.…”

“…1e,f). At 1000–1600 Ω, the predicted range of human internal resistance, 11 the effective power of the maXium unit was much lower than that of the VIO300D unit.…”

“…2 These results indicate that thermal damage to the serosa during ESD is the predominant cause of PECS rather than bacterial infection and fecal exposure after ESD. [7][8][9] Indeed, recent retrospective studies have reported injury to the muscular layer 10 and high total joule heat 11 during colorectal ESD are associated with the incidence of PECS.…”