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Ito S, Hotta K, Sekiguchi M, Takeuchi Y, Oka S, Yamamoto H, Shinmura K, Harada K, Uraoka T, Hisabe T, Sano Y, Kondo H, Horimatsu T, Kikuchi H, Kawamura T, Nagata S, Yamamoto K, Tajika M, Tsuji S, Kusaka T, Okuyama Y, Yoshida N, Moriyama T, Hasebe A, So S, Saito Y, Nakahira H, Ishikawa H, Matsuda T. Short-term outcomes of endoscopic resection for colorectal neuroendocrine tumors: Japanese multicenter prospective C-NET STUDY. Dig Endosc 2024; 36:942-951. [PMID: 37986226 DOI: 10.1111/den.14728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/19/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES The incidence of colorectal neuroendocrine tumors (NETs) has increased with colorectal cancer screening programs and increased colonoscopies. The management of colorectal NETs has recently shifted from radical surgery to endoscopic resection. We aimed to evaluate the short-term outcomes of various methods of endoscopic resection for colorectal NETs. METHODS Among those registered in the C-NET STUDY, patients with colorectal NETs who underwent endoscopic treatment as the initial therapy were included. Short-term outcomes, such as the en bloc resection rate and R0 resection (en bloc resection with tumor-free margin) rate, were analyzed based on treatment modalities. RESULTS A total of 472 patients with 477 colorectal NETs received endoscopic treatment. Of these, 418 patients with 421 lesions who met the eligibility criteria were included in the analysis. The median age of the patients was 55 years, and 56.9% of them were men. The lower rectum was the most commonly affected site (88.6%), and lesions <10 mm accounted for 87% of the cases. Endoscopic submucosal resection with a ligation device (ESMR-L, 56.5%) was the most common method, followed by endoscopic submucosal dissection (ESD, 31.4%) and endoscopic mucosal resection using a cap (EMR-C, 8.5%). R0 resection rates <10 mm were 95.5%, 94.8%, and 94.3% for ESMR-L, ESD, and EMR-C, respectively. All 16 (3.8%) patients who developed treatment-related complications could be treated conservatively. Overall, 23 (5.5%) patients had incomplete resection without independent clinicopathological risk factors. CONCLUSION ESMR-L, ESD, and EMR-C were equally effective and safe for colorectal NETs with a diameter <10 mm.
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Affiliation(s)
- Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masau Sekiguchi
- Endoscopy Division, Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shiro Oka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kensuke Shinmura
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Keita Harada
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yasushi Sano
- Gastrointestinal Center, Sano Hospital, Hyogo, Japan
| | - Hitoshi Kondo
- Department of Gastroenterology, Tonan Hospital, Hokkaido, Japan
| | - Takahiro Horimatsu
- Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Hidezumi Kikuchi
- Department of Gastroenterology and Hepatology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takuji Kawamura
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Shinji Nagata
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, JCHO Osaka Hospital, Osaka, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Aichi, Japan
| | - Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Toshihiro Kusaka
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yusuke Okuyama
- Department of Gastroenterology, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomohiko Moriyama
- International Medical Department, Kyushu University Hospital, Fukuoka, Japan
| | - Aki Hasebe
- Department of Gastroenterology, Shikoku Cancer Center, Ehime, Japan
| | - Suketo So
- Department of Gastroenterology, Tobata Kyoritsu Hospital, Fukuoka, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroko Nakahira
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hideki Ishikawa
- Department of Molecular-Targeting Prevention, Graduate School of Medicine Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
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Lee HJ, Seo Y, Oh CK, Lee JM, Choi HH, Gweon TG, Lee SH, Cheung DY, Kim JI, Park SH, Lee HH. Assessing risk stratification in long-term outcomes of rectal neuroendocrine tumors following endoscopic resection: a multicenter retrospective study. Scand J Gastroenterol 2024; 59:868-874. [PMID: 38587111 DOI: 10.1080/00365521.2024.2340008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVES While endoscopic resection of rectal neuroendocrine tumors (NETs) has significantly increased, long-term data on risk factors for recurrence are still lacking. Our aim is to analyze the long-term outcomes of patients with rectal NETs after endoscopic resection through risk stratification. METHODS In this multicenter retrospective study, we included patients who underwent endoscopic resection of rectal NETs from 2009 to 2018 and were followed for ≥12 months at five university hospitals. We classified the patients into three risk groups according to the clinicopathological status of the rectal neuroendocrine tumors: low, indeterminate, and high. The high-risk group was defined if the tumors have any of the followings: size ≥ 10 mm, lymphovascular invasion, muscularis propria or deeper invasion, positive resection margins, or mitotic count ≥2/10. RESULTS A total of 346 patients were included, with 144 (41.6%), 121 (35.0%), and 81 (23.4%) classified into the low-, indeterminate-, and high-risk groups, respectively. Among the high-risk group, seven patients (8.6%) received salvage treatment 28 (27-67) days after the initial endoscopic resection, with no reported extracolonic recurrence. Throughout the follow-up period, 1.1% (4/346) of patients experienced extracolonic recurrences at 56.5 (54-73) months after the initial endoscopic resection. Three of these patients (75%) were in the high-risk group and did not undergo salvage treatment. The risk of extracolonic recurrence was significantly higher in the high-risk group compared to the other groups (p = 0.039). CONCLUSION Physicians should be concerned about the possibility of metastasis during long-term follow-up of high-risk patients and consider salvage treatment.
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Affiliation(s)
- Hyun Jin Lee
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Department of Internal Medicine, Myongji Hospital, Goyang, Republic of Korea
| | - Yun Seo
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Kyo Oh
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Gastroenterology, Department of Internal Medicine, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University of Korea, Seoul, Republic of Korea
| | - Ji Min Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Hyun Ho Choi
- Department of Internal Medicine, Uijungbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijungbu, Republic of Korea
| | - Tae-Geun Gweon
- Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Sung-Hak Lee
- Department of Hospital Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dae Young Cheung
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Il Kim
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo-Heon Park
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Hee Lee
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Chen J, Ye J, Zheng X, Chen J. Endoscopic treatments for rectal neuroendocrine tumors: a systematic review and network meta-analysis. J Gastrointest Surg 2024; 28:301-308. [PMID: 38445925 DOI: 10.1016/j.gassur.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/09/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Conventional endoscopic mucosal resection (cEMR), EMR with a transparent cap, EMR using a ligation device (EMR-L), EMR after circumferential precutting (EMR-P), and endoscopic submucosal dissection (ESD) have been used for resecting rectal neuroendocrine tumors (r-NETs). However, there is no consensus regarding which is the best treatment. This study aimed to compare the outcomes of the aforementioned 5 techniques for resecting r-NETs by network meta-analysis. METHODS Electronic databases (PubMed, Cochrane Library, Embase, Ovid Medline, and Web of Science) were systematically searched to include relevant studies published from inception to September 1, 2023. The en bloc resection rate, histologic complete resection rate, positive lateral margin rate, positive vertical margin rate, adverse events rate, and procedure time were compared. RESULTS A total of 27 studies with a total of 2112 r-NETs were included, and the mean diameter of tumors was 6.24 mm. Pairwise meta-analysis showed that EMR-L and ESD had higher en bloc resection and histologic complete resection rates and lower positive vertical margin rate than those of cEMR in resecting r-NETs. Compared with ESD, EMR-L and EMR-P achieved similar resection rates and significantly shortened the procedure time without increasing adverse events. The network meta-analysis evaluated the surface under the cumulative ranking curves and revealed that EMR-L was the best modality for treating r-NETs considering the comprehensive results of the en bloc resection rate, histologic complete resection rate, positive lateral margin rate, positive vertical margin rate, adverse events rate, and procedure time. CONCLUSION EMR-L should be recommended as the first-line endoscopic treatment for small r-NETs.
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Affiliation(s)
- Jie Chen
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Jianfang Ye
- Department of Endocrinology and Metabolism, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Xiong Zheng
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Jianyong Chen
- Department of Gastroenterology and Hepatology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China.
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Hong SM, Baek DH. Endoscopic treatment for rectal neuroendocrine tumor: which method is better? Clin Endosc 2022; 55:496-506. [PMID: 35811403 PMCID: PMC9329644 DOI: 10.5946/ce.2022.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/23/2022] [Indexed: 12/07/2022] Open
Abstract
Recently, research on rectal neuroendocrine tumors (NETs) has increased during the last few decades. Rectal NETs measuring <10 mm without atypical features and confined to the submucosal layer have only 1% risk of metastasis, and the long-term survival probability of patients without metastasis at the time of diagnosis is approximately 100%. Therefore, the current guidelines suggest endoscopic resection of rectal NETs of <10 mm is regarded as a safe therapeutic option. However, there are currently no clear recommendations for technique selection for endoscopic resection. The choice of treatment modality for rectal NETs should be based on the lesion size, endoscopic characteristics, grade of differentiation, depth of vertical involvement, lymphovascular invasion, and risk of metastasis. Moreover, the complete resection rate, complications, and experience at the center should be considered. Modified endoscopic mucosal resection is the most suitable resection method for rectal NETs of <10 mm, because it is an effective and safe technique that is relatively simple and less time-consuming compared with endoscopic submucosal dissection. Endoscopic submucosal dissection should be considered when the tumor size is >10 mm, suctioning is not possible due to fibrosis in the lesion, or when the snaring for modified endoscopic mucosal resection does not work well.
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Affiliation(s)
- Seung Min Hong
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Hoffman A, Atreya R, Rath T, Neurath MF. Current Endoscopic Resection Techniques for Gastrointestinal Lesions: Endoscopic Mucosal Resection, Submucosal Dissection, and Full-Thickness Resection. Visc Med 2021; 37:358-371. [PMID: 34722719 DOI: 10.1159/000515354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background Endoscopic resection of dysplastic lesions in early stages of cancer reduces mortality rates and is recommended by many national guidelines throughout the world. Snare polypectomy and endoscopic mucosal resection (EMR) are established techniques of polyp removal. The advantages of these methods are their relatively short procedure times and acceptable complication rates. The latter include delayed bleeding in 0.9% and a perforation risk of 0.4-1.3%, depending on the size and location of the resected lesion. EMR is a recent modification of endoscopic resection. A limited number of studies suggest that larger lesions can be removed en bloc with low complication rates and short procedure times. Novel techniques such as endoscopic submucosal dissection (ESD) are used to enhance en bloc resection rates for larger, flat, or sessile lesions. Endoscopic full-thickness resection (EFTR) is employed for non-lifting lesions or those not easily amenable to resection. Procedures such as ESD or EFTR are emerging standards for lesions inaccessible to EMR techniques. Summary Endoscopic treatment is now regarded as first-line therapy for benign lesions. Key Message Endoscopic resection of dysplastic lesions or early stages of cancer is recommended. A plethora of different techniques can be used dependent on the lesions.
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Affiliation(s)
- Arthur Hoffman
- Department of Internal Medicine III, Aschaffenburg-Alzenau Clinic, Aschaffenburg, Germany
| | - Raja Atreya
- First Department of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Deutsches Zentrum Immuntherapie, DZI, Erlangen, Germany
| | - Timo Rath
- First Department of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Deutsches Zentrum Immuntherapie, DZI, Erlangen, Germany
| | - Markus Ferdinand Neurath
- First Department of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Deutsches Zentrum Immuntherapie, DZI, Erlangen, Germany
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Harada H, Suehiro S, Murakami D, Nakahara R, Shimizu T, Katsuyama Y, Miyama Y, Hayasaka K, Tounou S. Endoscopic submucosal dissection for small submucosal tumors of the rectum compared with endoscopic submucosal resection with a ligation device. World J Gastrointest Endosc 2017; 9:70-76. [PMID: 28250899 PMCID: PMC5311475 DOI: 10.4253/wjge.v9.i2.70] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/01/2016] [Accepted: 11/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for small rectal submucosal tumors (SMTs).
METHODS Between August 2008 and March 2016, 39 patients were treated with endoscopic submucosal resection with a ligation device (ESMR-L) (n = 21) or ESD (n = 18) for small rectal SMTs in this study. Twenty-five lesions were confirmed by histological evaluation of endoscopic biopsy prior to the procedure, and 14 lesions were not evaluated by endoscopic biopsy. The results for the ESMR-L group and the ESD group were retrospectively compared, including baseline characteristics and therapeutic outcomes.
RESULTS The rate of en bloc resection was 100% in both groups. Although the rate of complete endoscopic resection was higher in the ESD group than in the ESMR-L group (100% vs 95.2%), there were no significant differences between the two groups (P = 0.462). In one patient in the ESMR-L group with a previously biopsied tumor, histological complete resection with a vertical margin involvement of carcinoid tumor could not be achieved, whereas there was no incomplete resection in the ESD group. The mean length of the procedure was significantly greater in the ESD group than in the ESMR-L group (14.7 ± 6.4 min vs 5.4 ± 1.7 min, P < 0.05). The mean period of the hospitalization was also significantly longer in the ESD group than in the ESMR-L group (3.7 ± 0.9 d vs 2.8 ± 1.5 d, P < 0.05). Postoperative bleeding was occurred in one patient in the ESMR-L group.
CONCLUSION Both ESMR-L and ESD were effective for treatment of small rectal SMTs. ESMR-L was simpler to perform than ESD and took less time.
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Gaglia A, Sarkar S. Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection. Ann Gastroenterol 2016; 30:145-151. [PMID: 28243034 PMCID: PMC5320026 DOI: 10.20524/aog.2016.0104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/04/2016] [Indexed: 02/06/2023] Open
Abstract
Endoscopic mucosal resection (EMR) has been used in western countries to remove colonic polyps for at least the last two decades. Significant experience has been accumulated and the efficacy of the method has recently been evaluated in a large meta-analysis. A number of variations to modify the technique, including knife-assisted, cap-assisted, ligation devices, and underwater EMR, have been developed in an attempt to improve outcomes. However, to date there are only limited data comparing these techniques or demonstrating the superiority of any one of them. This article reviews the current evidence on the efficacy of each of these modified techniques.
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Affiliation(s)
- Asimina Gaglia
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Sanchoy Sarkar
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
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Zhang HP, Wu W, Yang S, Lin J. Endoscopic treatments for rectal neuroendocrine tumors smaller than 16 mm: a meta-analysis. Scand J Gastroenterol 2016; 51:1345-53. [PMID: 27367942 DOI: 10.1080/00365521.2016.1200140] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR), including conventional EMR (c-EMR) and modified EMR (m-EMR), was applied to remove small rectal neuroendocrine tumors (NETs). We aim to evaluate treatment outcomes of endoscopic submucosal dissection (ESD), m-EMR and c-EMR for rectal NETs <16 mm. METHODS The PubMed, Cochrane Library and Elsevier Science Direct were searched to identify eligible articles. After quality assessment and data extraction, meta-analysis was performed. The main outcomes were complete resection rate, overall complication rate, procedure time and local recurrence rate. RESULTS Compared with c-EMR, ESD could achieve higher complete resection rate (OR = 4.38, 95%CI: 2.43-7.91, p < 0.00001) without increasing overall complication rates (OR = 2.21, 95%CI: 0.56-8.70, p = 0.25). However, ESD was more time-consuming than c-EMR (MD = 6.72, 95%CI: 5.84-7.60, p < 0.00001). Compared with m-EMR, ESD did not differ from m-EMR in complete resection and overall complication rates (OR = 0.80, 95%CI: 0.51-1.27, p = 0.34; OR = 1.91, 95%CI: 0.75-4.86, p = 0.18, respectively). However, ESD was more time-consuming than m-EMR (MD = 12.21, 95%CI: 7.78-16.64, p < 0.00001). Compared with c-EMR, m-EMR could achieve higher complete resection rate (OR = 4.23, 95%CI: 2.39-7.50, p < 0.00001) without increasing overall complication rate (OR = 1.07, 95%CI: 0.35-3.32, p = 0.90). Moreover, m-EMR was not time-consuming than c-EMR (MD = 2.01, 95%CI: -0.37-4.40, p= 0.10). The local recurrence rate was 0.84% (9/1067) during follow-up. CONCLUSIONS Both ESD and m-EMR have great advantages over c-EMR in complete resection rate without increasing safety concern while m-EMR shares similar outcomes with ESD for rectal NETs <16 mm. The results should be confirmed by well-designed, multicenter, randomized controlled trials with large samples and long-term follow-ups from more countries.
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Affiliation(s)
- Hai-Ping Zhang
- a Department of Gastroenterology , Zhongshan Hospital of Wuhan University , Wuhan City , Hubei Province , China ;,b Department of Gastroenterology , Zhongnan Hospital of Wuhan University , Wuhan City , Hubei Province , China
| | - Wei Wu
- b Department of Gastroenterology , Zhongnan Hospital of Wuhan University , Wuhan City , Hubei Province , China
| | - Sheng Yang
- b Department of Gastroenterology , Zhongnan Hospital of Wuhan University , Wuhan City , Hubei Province , China
| | - Jun Lin
- a Department of Gastroenterology , Zhongshan Hospital of Wuhan University , Wuhan City , Hubei Province , China ;,b Department of Gastroenterology , Zhongnan Hospital of Wuhan University , Wuhan City , Hubei Province , China
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