Clinical outcomes of endoscopic submucosal dissection for laterally spreading tumors involving the dentate line

Safety and efficacy of ESD for laterally spreading tumors with hemorrhoids close to the dentate line

BACKGROUND

Endoscopic submucosal dissection (ESD) is a curative treatment for laterally spreading tumors (LSTs). However, the outcomes of ESD for LSTs with hemorrhoids remain largely unknown. Our study aimed to evaluate the usefulness of ESD in managing LSTs with hemorrhoids.

MATERIAL AND METHODS

We retrospectively collected 418 consecutive LST patients treated with ESD between 2011 and 2023. A retrospective comparative analysis was conducted.

RESULTS

There were 85 patients included in the hemorrhoids group and 333 patients included in the other group. The en-bloc resection rate, R0 resection rate, and curative resection rate were comparable in these two groups (p > 0.05). The LSTs with hemorrhoids have a significantly higher intraoperative bleeding rate during ESD when compared to the other group (12.9% vs. 5.4%, p = 0.028). Rates of intraoperative perforation and anal pain in the hemorrhoid group were significantly higher than those in the no-hemorrhoid group (2.4% vs. 0%, p = 0.041; 9.4% vs.0.6%, p < 0.001; respectively). Moreover, most of the related manifestations caused by hemorrhoids were relieved to various degrees after ESD.

CONCLUSIONS

ESD is a safe and effective treatment strategy for LSTs with hemorrhoids. A multi-center and prospective study should be conducted in the future to validate our results.

Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of rectal lesions involving the dentate line

BACKGROUND

The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line.

METHODS

We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed.

RESULTS

We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions.

CONCLUSION

ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

Endoscopic Submucosal Dissection for Resections Larger than 10 cm: Outcomes from a Portuguese Center

Background

Endoscopic submucosal dissection (ESD) is a minimally invasive technique for en bloc resection of superficial neoplastic lesions, independent of their size. However, for giant gastrointestinal superficial neoplasia, the risk of invasive cancer is higher, and ESD is typically challenging. Despite the increasing literature on giant resections, data on their efficacy and safety are still lacking.

Objective

The aim of this study was to describe ESD outcomes from a Portuguese center, compare them with other international studies, and analyze the possible risk factors influencing outcomes.

Methods

We conducted a retrospective single-center review using a prospectively collected database, including patients with rectal ESD resections larger than 10 cm, between January 2016 and December 2021. Clinical, procedural, and pathological data were collected and analyzed. Revision of the literature for comparison with international results was done through PubMed. Data were analyzed and statistical analysis performed, using Microsoft Excel and SPSS, to identify significant risk factors.

Results

The study included 15 rectal resections, with a mean diameter of 140.9 mm (range 105-270), corresponding to lesions of 125.9 mm (87-238). The overall en bloc resection rate was 100% (n = 15). According to ESGE criteria, procedure was considered curative in 53.3% (n = 8), non-curative with high risk in 13.3% (n = 2), and local-risk recurrence in 33.3% (n = 5). Adverse events occurred in 26.7% (n = 4): 1 minor perforation and 3 stenosis, most endoscopically managed. For non-curative resections with local-risk recurrence, surveillance without adjuvant therapy was performed in all cases. For high-risk non-curative resections, surgery was performed in 1 patient and adjuvant chemoradiation therapy in another. Follow-up (mean 16 months) demonstrated a recurrence rate of 0%. Statistical analysis revealed resection size ≥20 cm as a risk factor for perforation (p value 0.067), and involvement of ≥90% of the circumference and procedural time ≥4 h as risk factors for stenosis (p value 0.029 and 0.009, respectively).

Conclusions

Although challenging, ESD for giant lesions seems effective and safe, with a still relevant rate of complications, which were mostly endoscopically treated. Rigorous characterization of lesions is crucial to predict and avoid complications or the need for therapy escalation.

Technique, sedation, and clinical outcome of endoscopic submucosal dissection for rectal tumor with involvement of dentate line: A retrospective cohort study

Background

Endoscopic submucosal dissection (ESD) of rectal tumors involving the dentate line (RT-DL) is challenging because of the anatomical features of the anal canal. This study aimed to identify optimal techniques and sedation and to determine the clinical outcomes of ESD for RT-DL.

Methods

We retrospectively collected medical records and endoscopic results of patients who underwent ESD for rectal tumors between January 2012 and April 2021. Patients were divided into RT-DL and rectal tumors not involving the dentate line (RT-NDL) groups, as per involvement of the dentate line. The treatment results and clinical outcomes of the two groups were evaluated and analyzed. Additionally, subgroup analysis was performed in the RT-DL group for the sedation method involved.

Results

In total, 225 patients were enrolled and 22 were assigned to the RT-DL group. The complete resection rate (90.9% vs. 95.6%, P =0.336), delayed bleeding (13.6% vs. 5.9%, P =0.084), perforation (0% vs. 3.9%, P = 0.343), hospital stays (4.55 vs. 4.48 days, P = 0.869), and recurrence (0% vs. 0.5%) showed no significant group differences. However, in RT-DL group, the procedure time (78.32 vs. 51.10 min, P = 0.002) was longer and there was more perianal pain (22.7% vs. 0%, P = 0.001). The subgroup analysis revealed that deep sedation using propofol reduced perianal pain during the procedure (0/14 vs. 5/8, P = 0.002).

Conclusions

ESD of RT-DL is a safe and effective treatment despite the challenges of requiring a high level of technique and longer procedure time. In particular, ESD under deep sedation should be considered in patients with RT-DL to control perianal pain.

Efficacy and Safety of Endoscopic Submucosal Dissection for Rectal Tumors Extending Versus Not to the Dentate Line: A Systematic Review and Meta-Analysis

GOALS

To evaluate the outcomes of endoscopic submucosal dissection (ESD) for rectal tumors extending to the dentate line (RTDLs) compared with rectal tumors not extending to the dentate line (non-RTDLs).

BACKGROUND

There is limited composite data on the outcomes of ESD for RTDLs versus non-RTDLs.

STUDY

We performed a systematic review and meta-analysis of studies that reported the clinical outcomes of ESD for RTDLs and non-RTDLs. Main outcomes were pooled estimated rates of en bloc/complete/curative resection, local recurrence, and incidence of bleeding, perforation, stricture, anal pain, and fever.

RESULTS

Six studies were enrolled, including 265 cases of RTDLs and 788 cases of non-RTDLs. The en bloc resection rate was comparable for RTDLs and non-RTDLs [odds ratio (OR), 1.04; 95% confidence interval (CI), 0.55-1.95; P=0.90]. The complete resection rate was significantly lower for RTDLs (OR, 0.59; 95% CI, 0.41-0.83; P=0.003), as well as the curative resection rate (OR, 0.57; 95% CI, 0.38-0.87; P=0.010). The rates of stricture, postoperative anal pain and local recurrence were significantly higher for RTDLs than non-RTDLs (OR, 3.07; 95% CI, 1.01-9.31; P=0.05) (OR, 42.10; 95% CI, 4.73-374.97; P=0.0008) (OR, 3.00; 95% CI, 1.13-7.96; P=0.03), but the higher rates of postoperative bleeding and fever for RTDLs were not significantly (OR, 1.33; 95% CI, 0.53-3.30; P=0.54) (OR, 2.23; 95% CI, 0.55-9.07; P=0.26), as well as its lower perforation rate (OR, 0.85; 95% CI, 0.27-2.63; P=0.78).

CONCLUSIONS

Despite its inferior outcomes than non-RTDLs, ESD is still a feasible and safe treatment for RTDLs if appropriate lesions are treated by experienced operators.

Endoscopic submucosal dissection in tumors extending to the dentate line compared to proximal rectal tumors: a systematic review with meta-analysis

Endoscopic submucosal dissection (ESD) is a validated treatment for early rectal tumors, but whether this therapy is efficient or not for rectal tumors extending to the dentate line (RTDL) remains unclear. We performed a systematic review and meta-analysis to assess the effectiveness and safety of ESD in RTDL compared to non-RTDL. A search in PubMed, Scopus and the Cochrane library up to April 2020 was conducted to identify studies that compared ESD in both localizations (RTDL and non-RTDL), reporting at least one main outcome (en bloc, complete resection, recurrence). Secondary outcomes were adverse event occurrence. Five observational studies including 739 patients with a total of 201 RTDL and 538 non-RTDL were considered. The proportion of female sex (66% vs. 36.9%, P < 0.001) and tumor size [mean difference = 7.75, 95% confidence interval (CI): 3.01-12.49, P = 0.001] were higher in the RTDL group. There were no differences in en bloc resection rates between RTDL and non-RTDL groups [odds ratio (OR): 0.95, 95% CI: 0.50-1.79, P = 0.087]. The complete resection rate was significantly higher in the non-RTDL group (OR: 1.72, 95% CI: 1.18-2.53, P = 0.005, I2 = 0%). However, recurrence rates were comparable (RD: -0.04, 95% CI: -0.07 to 0.00, P = 0.06, I2 = 0%). Concerning adverse events, there were no differences in terms of perforation (OR: 0.9, 95% CI: 0.26-3.08, P = 0.86, I2 = 0%) or delayed bleeding (OR: 0.64, 95% CI: 0.17-2.42, P = 0.51, I2 = 35%). Anal pain rate was 28% (95% CI: 21.4-35.8%). ESD is an effective and safe therapeutic approach for RTDL with comparable recurrence rate to non-RTDL. The lower complete resection rate in RTDL needs to be clarified in studies.

Application value of pre-cutting endoscopic mucosal resection in treatment of colorectal laterally spreading tumors

BACKGROUND

Endoscopic mucosal resection (EMR) with precutting (Pre-cut-EMR) is an improvement on the basis of EMR, which combines the technical advantages of EMR and endoscopic submucosal dissection (ESD) to form a new endoscopic resection method and is more and more widely used in clinical practice. This study preliminarily explored the clinical value of Pre-cut-EMR in the treatment of colorectal laterally spreading tumors (LSTs) through retrospective analysis.

AIM

To explore the application value of Pre-cut-EMR in the treatment of colorectal LSTs.

METHODS

A total of 84 patients with colorectal LSTs who were treated at our department from January 2016 to December 2019 were selected as the research subjects. The clinical data of all patients were retrospectively analyzed to summarize the clinical characteristics of colorectal LSTs. All patients underwent Pre-cut-EMR, and the average operation time, overall resection rate, complete resection rate, and the incidence of complications were recorded. Colonoscopy was performed at 3, 6, and 12 mo after the operation to evaluate the recurrence. The relevant literature on ESD treatment of colorectal LSTs was retrieved through China HowNet and Wanfang Database, and the pre-cut-EMR group and ESD group were compared for the curative effect on colorectal LSTs.

RESULTS

The average diameter of colorectal LSTs in the 84 cases was 25.6 mm. The endoscopic morphological classification was mainly granular. According to Kudo pit classification, types Ⅲ and Ⅳ were common, with type ⅢL being the most common. Tubular adenoma and villous adenoma were common pathological types. All 84 patients with colorectal LSTs underwent endoscopic resection successfully. One of them converted to ESD and one to EPMR. The pre-cut-EMR resection rate was 97.6%, and the average operation time was 24.5 min. There were three cases with positive basal margins, and the complete resection rate was 96.4%. Two cases of bleeding and one case of perforation occurred during the operation, and the complication rate was 3.6%. None of the 78 patients who were followed had recurrence, and the recurrence rate was 0%. Compared with the research data obtained by Xu et al, Yu et al, and Qiuhai et al, the operation time of the Pre-cut-EMR group was significantly lower than that of the ESD group (χ² = 21.037, P = 0.001), but there was no statistical difference in the overall resection rate, complication rate, complete resection rate, or recurrence rate compared with the ESD group (P > 0.05).

CONCLUSION

Pre-cut-EMR is effective and safe for colorectal LST treatment, and has high clinical value. This surgical method deserves to be widely promoted due to its simplicity, being easy to learn, and low equipment requirements.

Rectal neoplasia extending to the dentate line: clinical outcomes of endoscopic submucosal dissection

BACKGROUND

The European Society of Gastrointestinal Endoscopy (ESGE) and the Japan Gastroenterological Endoscopy Society (JGES) give no specific recommendations on the best treatment for colorectal neoplasia involving the dental line (DLCN).

OBJECTIVE

Aim of this study was to analyse efficacy and safety of Endoscopic Submucosal Dissection in the treatment of colorectal neoplasia involving the dentate line (DLCN) compared to non-DLCN.

DESIGN

Retrospective study.

PATIENTS

We retrospectively evaluated all consecutive patients undergoing ESD for rectal neoplasia at two endoscopical tertiary referral centers (Italy and Japan) from January 2008 to December 2019.

MAIN OUTCOME MEASURES

Anthropometric, clinical, procedural, and follow-up data was collected, analysed, and compared between patients with DLCN and patients with non-DLCN.

RESULTS

Overall, 314 patients were enrolled (163 female, 51.9%). Mean age was 68 years (range, 32-92 years). En-bloc resection was achieved in 311/314 (99%) patients. Lesion size was higher in DLCN group than in the non-DLCN group (46.1 vs 38.9 mm; p = .03). Submucosal invasion rate was also higher in the DLCN group (29.6 vs 18.4%, p = .04). Procedure time was significantly longer in the DLCN group, (89.6 vs. 73.1 min; p = .002). Hospitalization length following ESD was similar in both groups.

LIMITATIONS

Retrospective study design.

CONCLUSIONS

ESD seems to be safe and effective in the treatment of colorectal neoplasia involving the dentate line and can be considered the best therapeutic strategy.

Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction

OBJECTIVE

The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs.

DESIGN

EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC).

RESULTS

Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027).

CONCLUSION

EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.

Endoscopic submucosal dissection in rectal tumors extending or not to the dentate line: A comparative analysis

BACKGROUND

The feasibility of endoscopic submucosal dissection (ESD) in rectal tumors extending to the dentate line (RTDL) is unclear.

AIMS

To analyze the outcomes of ESD in RTDL compared to non-RTDL, with a special focus on the lower rectum location.

METHODS

Observational multicenter retrospective study. All patients with a rectal tumor who underwent ESD in 2013-2017 were included. A comparative analysis between RTDL and non-RTDL groups was done.

RESULTS

Two-hundred and twenty-eight patients (median age: 69 years, range: 33-89, 51.3% male) with RTDL (n = 65, 28.5%) and non-RTDL lesions (n = 163, 71.5%) were included. There were no significant differences between the en-bloc (89.2% vs. 90.8%, p = 0.718), complete (60% vs. 71.8%, p = 0.084) and curative resection rates (58.5% vs. 68.7%, p = 0.141). The overall complication rate (4.6% vs. 8%, p = 0.370) was not different, independently of the rectal location. Local recurrence was higher in RTDL (7.3% vs. 1.5%, p = 0.065). The indication for surgery due to non-curative resections in the lower rectum was lower in RTDL (9.2% vs. 14.6%, p = 0.378).

CONCLUSION

The safety, effectiveness and long-term impact of ESD in RTDL and non-RTDLs is comparable. Local recurrence in the lower rectum may be higher in RTDL.