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Kawaguti FS, Kimura CMS, Moura RN, Safatle-Ribeiro AV, Nahas CSR, Marques CFS, de Rezende DT, Segatelli V, Cotti GCDC, Ribeiro Junior U, Maluf-Filho F, Nahas SC. Impact of a Routine Colorectal Endoscopic Submucosal Dissection in the Surgical Management of Nonmalignant Colorectal Lesions Treated in a Referral Cancer Center. Dis Colon Rectum 2023; 66:e834-e840. [PMID: 36574289 DOI: 10.1097/dcr.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent data show an increasing number of abdominal surgeries being performed for the treatment of nonmalignant colorectal polyps in the West but in settings in which colorectal endoscopic submucosal dissection is not routinely performed. This study evaluated the number of nonmalignant colorectal lesions referred to surgical treatment in a tertiary cancer center that incorporated magnification chromoendoscopy and endoscopic submucosal dissection as part of the standard management of complex colorectal polyps. OBJECTIVE The study aimed to estimate the number of patients with nonmalignant colorectal lesions referred to surgical resection at our institution after the standardization of routine endoscopic submucosal dissection and to describe outcomes for patients undergoing colorectal endoscopic submucosal dissection. DESIGN Single-center retrospective study from a prospectively collected database of endoscopic submucosal dissections and colorectal surgeries performed between January 2016 and December 2019. SETTING Reference cancer center. PATIENTS Consecutive adult patients with complex nonmalignant colorectal polyps were included. INTERVENTIONS Patients with nonmalignant colorectal polyps were treated by endoscopic submucosal dissection or surgery (elective colectomy, rectosigmoidectomy, low anterior resection, or proctocolectomy). MAIN OUTCOMES MEASURES The primary outcome measure was the percentage of patients referred to colorectal surgery for nonmalignant lesions. RESULTS In the study period, 1.1% of 825 colorectal surgeries were performed for nonmalignant lesions, and 97 complex polyps were endoscopically removed by endoscopic submucosal dissection. The en bloc, R0, and curative resection rates of endoscopic submucosal dissection were 91.7%, 83.5%, and 81.4%, respectively. The mean tumor size was 59 (SD 37.8) mm. Perforations during endoscopic submucosal dissection occurred in 3 cases, all treated with clipping. One patient presented with a delayed perforation 2 days after the endoscopic resection and underwent surgery. The mean follow-up period was 3 years, with no tumor recurrence in this cohort. LIMITATIONS Single-center retrospective study. CONCLUSIONS A workflow that includes assessment of the lesions with magnification chromoendoscopy and resection through endoscopic submucosal dissection can lead to a very low rate of abdominal surgery for nonmalignant colorectal lesions. See Video Abstract at http://links.lww.com/DCR/C123 . IMPACTO DE LA DISECCIN SUBMUCOSA ENDOSCPICA COLORRECTAL DE RUTINA EN EL MANEJO QUIRRGICO DE LESIONES COLORRECTALES NO MALIGNAS TRATADAS EN UN CENTRO ONCOLGICO DE REFERENCIA ANTECEDENTES:Datos recientes muestran un número cada vez mayor de cirugías abdominales realizadas para el tratamiento de pólipos colorrectales no malignos en Occidente, pero no en los entornos donde la disección submucosa endoscópica colorrectal se realiza de forma rutinaria. El estudio evaluó el número de lesiones colorrectales no malignas referidas a tratamiento quirúrgico en un centro oncológico terciario, que incorporó cromoendoscopia de aumento y disección submucosa endoscópica como parte del manejo estándar de pólipos colorrectales complejos.OBJETIVO:Estimar el número de pacientes con lesiones colorrectales no malignas referidos para resección quirúrgica en nuestra institución, después de la estandarización de la disección submucosa endoscópica de rutina y describir los resultados para los pacientes sometidos a disección submucosa endoscópica colorrectal.DISEÑO:Estudio retrospectivo de un solo centro, a partir de una base de datos recolectada prospectivamente de disecciones submucosas endoscópicas y cirugías colorrectales realizadas entre enero de 2016 y diciembre de 2019.AJUSTE:Centro oncológico de referencia.PACIENTES:Pacientes adultos consecutivos con pólipos colorrectales no malignos complejos.INTERVENCIONES:Pacientes con pólipos colorrectales no malignos tratados mediante disección submucosa endoscópica o cirugía (colectomía electiva, rectosigmoidectomía, resección anterior baja o proctocolectomía).PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primario fue el porcentaje de pacientes remitidos a cirugía colorrectal por lesiones no malignas.RESULTADOS:En el período, 1,1% de 825 cirugías colorrectales fueron realizadas por lesiones no malignas y 97 pólipos complejos fueron extirpados por. disección submucosa endoscópica. Las tasas de resección en bloque, R0 y curativa de disección submucosa endoscópica fueron 91,7%, 83,5% y 81,4%, respectivamente. El tamaño tumoral medio fue de 59 (DE 37,8) mm. Se produjeron perforaciones durante la disección submucosa endoscópica en 3 casos, todos tratados con clipaje. Un paciente presentó una perforación diferida 2 días después de la resección endoscópica y fue intervenido quirúrgicamente. El seguimiento medio fue de 3 años, sin recurrencia tumoral en esta cohorte.LIMITACIONES:Estudio retrospectivo de un solo centro.CONCLUSIONES:Un flujo de trabajo que incluye la evaluación de las lesiones con cromoendoscopia de aumento y resección a través de disección submucosa endoscópica, puede conducir a una tasa muy baja de cirugía abdominal para lesiones colorrectales no malignas. Consulte Video Resumen en http://links.lww.com/DCR/C123 . (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Fábio S Kawaguti
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Cintia Mayumi Sakurai Kimura
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Renata Nobre Moura
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Caio Sergio Rizkallah Nahas
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Daniel Tavares de Rezende
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Vanderlei Segatelli
- Division of Pathology, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Ulysses Ribeiro Junior
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
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2
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Gambitta P, Fontana P, Fanetti I, Veglia G, Vertemati M, Armellino A, Aseni P. Diagnostic Accuracy of Endoscopic Ultrasonography in Selecting Patients for Endoscopic Submucosal Dissection for Early Gastrointestinal Neoplasms. J Clin Med 2023; 12:jcm12072505. [PMID: 37048589 PMCID: PMC10094822 DOI: 10.3390/jcm12072505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Tumor invasion depth and lymph node metastasis determine the prognosis of gastrointestinal (GI) neoplasms. GI neoplasms limited to mucosa (m1 or m2) and superficial submucosa (sm1) can be treated effectively with minimally invasive endoscopic therapy, while the deep invasion of the submucosa (sm2 or sm3) is associated with lymph node metastasis, and surgical resection is required. Correct staging is therefore crucial for preoperative evaluation and planning. Endoscopic ultrasonography (EUS) can be used to detect the depth of invasion due to its close proximity to the lesion. The diagnostic accuracy of EUS, when compared to conventional endoscopic staging, is debated as it can under- or overstage the lesion. We aim in this study to determine if EUS can accurately differentiate mucosal from submucosal GI neoplasms to select patients with early GI lesions for endoscopic submucosal dissection (ESD) or surgery. From March 2014 to February 2022, 293 patients with early superficial GI neoplasms were admitted to our endoscopic unit for EUS staging. To evaluate the accuracy of EUS, we compared the preoperative EUS findings with the definitive histopathologic findings on the resected specimen. Overall, 242 of 293 lesions were correctly staged by EUS (82.59%). In the evaluation of submucosal invasion or deeper, EUS understaged 38 of 293 (12.96%) and overstaged 13 of 293 (4.43%) lesions. EUS has excellent accuracy in staging superficial GI neoplasms; its use is highly recommended before ESD since it can also detect lymph node metastases around the lesions, thus changing the indication from ESD to surgery.
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Affiliation(s)
- Pietro Gambitta
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Paola Fontana
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Ilaria Fanetti
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Giulia Veglia
- Department of Gastroenterology, Ospedale Civile di Legnano, ASST-Ovest Milanese, 20025 Legnano, Italy
| | - Maurizio Vertemati
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
| | - Antonio Armellino
- Endoscopy Division, Ospedale San Leopoldo Mandic di Merate, ASST Lecco, 23807 Lecco, Italy
| | - Paolo Aseni
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
- Department of Emergency, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Correspondence:
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3
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Kobayashi N, Takeuchi Y, Ohata K, Igarashi M, Yamada M, Kodashima S, Hotta K, Harada K, Ikematsu H, Uraoka T, Sakamoto N, Doyama H, Abe T, Katagiri A, Hori S, Michida T, Yamaguchi T, Fukuzawa M, Kiriyama S, Fukase K, Murakami Y, Ishikawa H, Saito Y. Outcomes of endoscopic submucosal dissection for colorectal neoplasms: Prospective, multicenter, cohort trial. Dig Endosc 2022; 34:1042-1051. [PMID: 34963034 DOI: 10.1111/den.14223] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/07/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endoscopic mucosal resection (EMR) is the gold standard for the treatment of noninvasive large colorectal lesions, despite challenges associated with nonlifting lesions and a high rate of local recurrence. Endoscopic submucosal dissection (ESD) offers the possibility of overcoming these EMR limitations. However, a higher risk of complications and longer procedure time prevented its dissemination. As ESD now provides more stable results because of standardized techniques compared with those used earlier, this study aimed to quantify the rates of en bloc and curative resections, as well as ESD complications, in the present situation. METHODS A multicenter, large-scale, prospective cohort trial of ESD was conducted at 20 institutions in Japan. Consecutive patients scheduled for ESD were enrolled from February 2013 to January 2015. RESULTS ESD was performed for 1883 patients (1965 lesions). The mean procedure time was 80.6 min; en bloc and curative resections were achieved in 1759 (97.0%) and 1640 (90.4%) lesions, respectively, in epithelial lesions ≥20 mm. Intra- and postprocedural perforations occurred in 51 (2.6%) and 12 (0.6%) lesions, respectively, and emergency surgery for adverse events was performed in nine patients (0.5%). CONCLUSIONS This trial conducted after the standardization of the ESD technique throughout Japan revealed a higher curability, shorter procedure time, and lower risk of complications than those reported previously. Considering that the target lesions of ESD are more advanced than those of EMR, ESD can be a first-line treatment for large colorectal lesions with acceptable risk and procedure time. (Clinical Trial Registration: UMIN000010136).
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Affiliation(s)
- Nozomu Kobayashi
- Department of Gastroenterology, Tochigi Cancer Center, Tochigi, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center, Tokyo, Japan
| | - Masahiro Igarashi
- Division of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shinya Kodashima
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keita Harada
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University Hospital, Tokyo, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Takashi Abe
- Department of Gastroenterology, Hanwa Sumiyoshi General Hospital, Osaka, Japan.,Department of Gastroenterology, Takarazuka Municipal Hospital, Hyogo, Japan
| | - Atsushi Katagiri
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shinichiro Hori
- Department of Gastroenterology, NHO Shikoku Cancer Center, Ehime, Japan
| | - Tomoki Michida
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.,Department of Internal Medicine, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Takehito Yamaguchi
- Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan.,Department of Internal Medicine, Japan Community Healthcare Organization Funabashi Central Hospital, Chiba, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | | | - Kazutoshi Fukase
- Department of Internal Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan.,Department of Internal Medicine, Yamagata Prefectural Kahoku Hospital, Yamagata, Japan
| | | | - Hideki Ishikawa
- Department of Molecular-Targeting Cancer Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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4
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Yang D, Draganov PV. Clinical Updates in Colorectal Endoscopic Submucosal Dissection. Clin Gastroenterol Hepatol 2022; 20:269-271. [PMID: 34774551 DOI: 10.1016/j.cgh.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida.
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5
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Imai K, Hotta K, Ito S, Yamaguchi Y, Kishida Y, Yabuuchi Y, Yoshida M, Kawata N, Tanaka M, Kakushima N, Takizawa K, Ishiwatari H, Matsubayashi H, Mori K, Ono H. A risk-prediction model for en bloc resection failure or perforation during endoscopic submucosal dissection of colorectal neoplasms. Dig Endosc 2020; 32:932-939. [PMID: 31883411 DOI: 10.1111/den.13619] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/25/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Technical difficulties in colorectal endoscopic submucosal dissections (ESD) result in en bloc resection failure or perforation. This study aimed to develop and validate a risk score for predicting en bloc resection failure or perforation in ESD of colorectal neoplasms. METHODS This single-center observational study included 1133 colorectal neoplasms treated with ESD in a Japanese tertiary cancer center. With a derivation set (n = 716), we performed multiple logistic regression to identify significant risk factors for en bloc resection failure or perforation. Based on odds ratios, we developed a risk score, ranging from 0 to 10: 0-1 'low risk' (LR); 2-4 'moderate risk' (MR); and 5-10 'high risk' (HR). An independent validation set comprised prospectively enrolled subjects (n = 417) that underwent ESDs from January 2014 to August 2016. The performance of the risk score for predicting en bloc resection failure or perforation for each risk tier was evaluated. RESULTS The baseline incidences of en bloc resection failure or perforation were 14.5% and 5.5% in the derivation and validation sets, respectively. We identified the following significant risk factors: endoscopist experience, tumor location, morphology, scope operability, underlying fold, and fold convergence. In the validation set, the incidences of en bloc resection failure or perforation were 0% in the LR tier (n = 62; 14.8%), 2.3% in the MR tier (n = 293; 70.4%), and 25.8% in the HR tier (n = 62; 14.8%) (P < 0.001, Cochran-Armitage trend test). CONCLUSIONS A risk scoring system, which was developed and prospectively validated, can successfully estimate the incidence of en bloc resection failure or perforation.
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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6
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Abe S, Saito Y, Tanaka Y, Ego M, Yanagisawa F, Kawashima K, Takamaru H, Sekiguchi M, Yamada M, Sakamoto T, Matsuda T, Goto O, Yahagi N. A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study. Endoscopy 2020; 52:780-785. [PMID: 32207119 DOI: 10.1055/a-1120-8533] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study aimed to demonstrate the feasibility of endoscopic hand-suturing (EHS) and attainability of sustained closure after colorectal endoscopic submucosal dissection (ESD). METHODS EHS was defined as uninterrupted endoscopic suturing of the mucosal defect after colorectal ESD using an absorbable barbed suture and a through-the-scope needle holder. Following individual EHS training using an ex vivo porcine colonic model, two experienced endoscopists performed EHS. Repeat colonoscopy was performed on the third or fourth day after ESD to examine the EHS site. The primary end point was the complete EHS closure rate, and secondary end points were sustained closure and post-ESD bleeding rates. RESULTS 11 lesions were included. Median size of the mucosal defect was 38 mm (range 25 - 55 mm) and the lesion characteristics were as follows: lower rectum/upper rectum/ascending colon/cecum = 3/3/2/3, and 0-IIa/0-Is + IIa/others = 5/4/2. EHS was not attempted in two patients owing to difficulty in colonoscope reinsertion after ESD and intraoperative perforation, respectively. EHS was performed for nine lesions, and the complete EHS closure rate was 73 %. Median procedure time for suturing was 56 minutes (range 30 - 120 minutes) and median number of stitches was 8 (range 6 - 12). Sustained closure and post-ESD bleeding rates were 64 % and 9 %, respectively. CONCLUSIONS EHS achieved complete and sustained closure in the colorectum. However, EHS is not currently clinically applicable given the long procedure time. Further modifications of the technique and devices are desirable.
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Affiliation(s)
- Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yusaku Tanaka
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Mai Ego
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | | | | | | | - Masau Sekiguchi
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
| | - Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, Tokyo, Japan
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7
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Mehta N, Abushahin A, Sadaps M, Alomari M, Vargo J, Patil D, Lopez R, Kalady M, Delaney CP, Gorgun E, Church J, Saito Y, Burke CA, Bhatt A. Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors. Surg Endosc 2020; 35:2500-2508. [PMID: 32472496 DOI: 10.1007/s00464-020-07660-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD). METHODS In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors. RESULTS A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273). CONCLUSION Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.
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Affiliation(s)
- Neal Mehta
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Desk A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Ashraf Abushahin
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Meena Sadaps
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad Alomari
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Deepa Patil
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Matthew Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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8
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Nishimura M, Saito Y, Nakanishi Y, Shia J, Lauwers GY, Wallace MB. Pathology definitions and resection strategies for early colorectal neoplasia: Eastern versus Western approaches in the post-Vienna era. Gastrointest Endosc 2020; 91:983-988. [PMID: 31874160 DOI: 10.1016/j.gie.2019.12.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/07/2019] [Indexed: 12/11/2022]
Abstract
There is a well-known discrepancy between East and West classifications of colorectal neoplasm, especially "intramucosal carcinoma," categorized as subgroup 4.4 in the Vienna classification, usually recognized as high-grade dysplasia in the United States and as carcinoma in situ in Japan. Focusing on management, in the current National Comprehensive Cancer Network algorithm, high-grade dysplasia, carcinoma in situ, and intramucosal carcinoma are managed similarly, whereas submucosal invasion by carcinoma requires en bloc resection. To bridge the differences with regard to these conceptual problems in the definition and management of carcinoma in situ and intramucosal carcinoma, endoscopists and pathologists from Japan and the United States gathered and discussed from their perspectives how to accurately assess specimens of en bloc/piecemeal resection and to effectively predict lymph node metastasis risk.
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Affiliation(s)
- Makoto Nishimura
- Gastroenterology, Hepatology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Hospital, Tokyo, Japan
| | - Yukihiro Nakanishi
- Department of Pathology, Moffitt Cancer Center; Associate Professor, Departments of Pathology, Cell Biology & Oncologic Sciences, University of South Florida
| | - Jinru Shia
- Gastrointestinal Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory Y Lauwers
- Department of Pathology, Moffitt Cancer Center; Associate Professor, Departments of Pathology, Cell Biology & Oncologic Sciences, University of South Florida
| | - Michael B Wallace
- H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, Tampa, Florida, USA, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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9
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Wang L, Zhao L, Wang X. Concerns about the safety and efficacy of hot avulsion as an adjunct to EMR. Gastrointest Endosc 2019; 90:997. [PMID: 31759426 DOI: 10.1016/j.gie.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/02/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Lan Wang
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lili Zhao
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Xiang Wang
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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10
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Russo P, Barbeiro S, Awadie H, Libânio D, Dinis-Ribeiro M, Bourke M. Management of colorectal laterally spreading tumors: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E239-E259. [PMID: 30705959 PMCID: PMC6353652 DOI: 10.1055/a-0732-487] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/04/2018] [Indexed: 12/17/2022] Open
Abstract
Objective and study aims To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST). Methods Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model. Results Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 - 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 - 92.9 %, I 2 = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 - 95.5 %, vs. 84 % 95 % CI 78.1 - 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 - 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 - 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 - 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 - 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 - 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 - 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 - 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST. Conclusions EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.
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Affiliation(s)
- Pedro Russo
- Gastroenterology Department, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Sandra Barbeiro
- Gastroenterology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Diogo Libânio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Mario Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,CINTESIS/MEDCIDS, Porto Faculty of Medicine, Portugal
| | - Michael Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, New South Wales, Australia
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11
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Sato Y, Kudo SE, Ichimasa K, Matsudaira S, Kouyama Y, Kato K, Baba T, Wakamura K, Hayashi T, Kudo T, Ogata N, Mori Y, Misawa M, Toyoshima N, Ishigaki T, Yagawa Y, Nakamura H, Sakurai T, Shakuo Y, Suzuki K, Kudo Y, Hamatani S, Ishida F, Miyachi H. Clinicopathological features of T1 colorectal carcinomas with skip lymphovascular invasion. Oncol Lett 2018; 16:7264-7270. [PMID: 30546465 DOI: 10.3892/ol.2018.9527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/31/2018] [Indexed: 11/05/2022] Open
Abstract
With recent advances in endoscopic treatment, many T1 colorectal carcinomas (CRCs) are resected endoscopically with a negative margin. However, some lesions exhibit skip lymphovascular invasion (SLVI), which is defined as the discontinuous foci of the tumor cells within the colon wall. The aim of the present study was to reveal the clinicopathological features of T1 CRCs with SLVI and validate the Japanese guidelines regarding SLVI. A total of 741 patients with T1 CRCs that were resected surgically between April 2001 and October 2016 in our hospital were divided into two groups: With SLVI and without SLVI. Clinicopathological features compared between the two groups were patient's gender, age, tumor size, location, morphology, lymphovascular invasion, tumor differentiation, tumor budding and lymph node metastasis. The incidence of T1 CRCs with SLVI was 0.9% (7/741). All cases with SLVI were found in the sigmoid colon or rectum. T1 CRCs with SLVI showed significantly higher rates of lymphovascular invasion than those without SLVI (P<0.01). In conclusion, lymphovascular invasion was a significant risk factor for SLVI in T1 CRCs, and for which surgical colectomy was necessary. The Japanese guidelines are appropriate regarding SLVI. Registered in the University Hospital Medical Network Clinical Trials Registry (UMIN000027097).
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Affiliation(s)
- Yuta Sato
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Shingo Matsudaira
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yuta Kouyama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Kazuki Kato
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Toshiyuki Baba
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Kunihiko Wakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Noriyuki Ogata
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Naoya Toyoshima
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Tomoyuki Ishigaki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yusuke Yagawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Hiroki Nakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Tatsuya Sakurai
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yukiko Shakuo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Kenichi Suzuki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yui Kudo
- Endoscopic Division, Kudo Clinic, Akita 010-0001, Japan
| | - Shigeharu Hamatani
- Department of Pathology, Jikei University School of Medicine, Tokyo 105-8471, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan.,Department of Gastroenterology, Kakogawa Central Hospital, Kakogawa 675-8611, Japan
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12
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Nagai K, Hayashi Y, Honma K, Sakatani A, Yoshii S, Fujinaga T, Maekawa A, Tsujii Y, Hiyama S, Shinzaki S, Watabe K, Iijima H, Tsujii M, Mizushima T, Morii E, Takehara T. Adenoma of colorectal laterally spreading tumor nongranular type with biological phenotypic features similar to cancer. J Gastroenterol Hepatol 2018; 33:1853-1863. [PMID: 29767452 DOI: 10.1111/jgh.14284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/03/2018] [Accepted: 04/27/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Colorectal laterally spreading tumors (LSTs) are morphologically subdivided into granular (LST-G) and nongranular (LST-NG) categories. We aimed to elucidate the differences in oncogenic characteristics between the two types. METHODS Laterally spreading tumors resected by endoscopic submucosal dissection and surgery from March 2009 to May 2017 were examined for p53 positivity, Ki-67 labeling index (LI), microvessel density, degree of fibrosis, intensities of inducible nitric oxide synthase (iNOS) and nitrotyrosine (NT), and expression of acid mucins. We compared these factors between adenomas, noninvasive cancers, and invasive cancers, both LST-G and LST-NG. RESULTS Ninety-three LST-G (53 adenomas [LST-GA] and 40 cancers [LST-GC]) and 55 LST-NG (24 adenomas [LST-NGA] and 31 cancers [LST-NGC]) were evaluated. Although p53 positivity was lower in LST-GA than in LST-NGA (P < 0.001), there was no difference between LST-GC and LST-NGC. Ki-67 LI was higher in LST-NGA than in LST-GA (P < 0.001) and higher in LST-NGC than in LST-GC of noninvasive cancers (P < 0.001). Microvessel density and degree of fibrosis were higher in LST-NGA than in LST-GA (P < 0.001), and intensities of iNOS and NT were also higher in LST-NGA than in LST-GA (P < 0.001). Expression of acid mucins was lower in LST-NGA than in LST-GA (P < 0.001). Although there were significant differences in p53 positivity, Ki-67 LI, microvessel density, degree of fibrosis, intensities of iNOS and NT, and expression of acid mucins between LST-GA and LST-NGA, these factors were only slightly different between LST-GC and LST-NGC of invasive cancers. CONCLUSIONS Unlike LST-GA, LST-NGA possessed phenotypic features similar to cancer.
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Affiliation(s)
- Kengo Nagai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiichiro Honma
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akihiko Sakatani
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shunsuke Yoshii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuji Fujinaga
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akira Maekawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Hiyama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shinichiro Shinzaki
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenji Watabe
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masahiko Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
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13
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Jeong YH, Lee J, Kim SW, Seo GS, Kim HS, Joo YE. Clinicopathological feature and treatment outcome of patients with colorectal laterally spreading tumors treated by endoscopic submucosal dissection. Intest Res 2018; 17:127-134. [PMID: 30301342 PMCID: PMC6361012 DOI: 10.5217/ir.2018.00075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) is an advanced technique that can be used to treat precancerous and early colorectal neoplasms by facilitating en bloc resection regardless of tumor size. In our study, we investigated the clinicopathological feature and the treatment outcome of patients with colorectal laterally spreading tumors (LSTs) that were treated by ESD. METHODS The study enrolled all of 210 patients with colorectal LSTs who underwent ESD. Clinical outcomes were analyzed by retrospectively reviewing medical records. RESULTS A cancerous pit pattern (Vi/Vn) was more common in pseudo-depressed (PD) subtype than in flat elevated (FE) subtype. The incidence of adenocarcinoma in the PD subtype and nodular mixed (NM) subtypes was significantly higher than in the homogenous (HG) subtype and FE subtype. The en bloc and R0 resection rates were 89.0% and 85.7%, respectively. The bleeding and perforation rates were 5.2% and 1.9%, respectively. The mean procedure time was much longer in the PD subtype than in the FE subtype. The en bloc resection rate was significantly higher in the NM subtype than in the HG subtype. However, there were no statistically significant differences in mean procedure time, en bloc resection rate, R0 resection rate, bleeding rate, or perforation rate between LST-granular and LST-nongranular types. CONCLUSIONS These results indicate that ESD is acceptable for treating colorectal LSTs concerning en bloc resection, curative resection, and risk of complications. Careful consideration is required for complete resection of the PD subtype and NM subtype because of their higher malignant potential.
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Affiliation(s)
- Young-Hoon Jeong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jun Lee
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Sang-Wook Kim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Geom-Seog Seo
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Young-Eun Joo
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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14
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Hong JY, Kweon SS, Lee J, Kim SW, Seo GS, Kim HS, Joo YE. Risk factors for procedure-related complications after endoscopic resection of colorectal laterally spreading tumors. Medicine (Baltimore) 2018; 97:e12589. [PMID: 30313045 PMCID: PMC6203567 DOI: 10.1097/md.0000000000012589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Colorectal laterally spreading tumors (LSTs) are large and flat elevated neoplasms with diameters of at least 10 mm. Endoscopic resection of LSTs, with their large size and broad base, is difficult and dangerous compared with the resection of polypoid neoplasms. This study aimed to determine the risk factors for procedure-related complications including bleeding and perforation after endoscopic resection of LSTs.Patients with colorectal LST undergoing endoscopic resection at 5 university hospitals in Honam Province of South Korea were enrolled, and their records about patients, lesions, and procedure parameters associated with the occurrence of complications were reviewed retrospectively. Logistic regression analysis was performed to identify risk factors for complications.The frequency of comorbidities in bleeding group was significantly higher than in the no bleeding group. The frequency of bleeding was significantly higher in lesions with adenocarcinoma than in lesions with low or high-grade dysplasia. The frequency of bleeding was significantly higher in piecemeal resection than in en bloc resection. The frequency of perforation was significantly higher in endoscopic mucosal resection-precutting (EMR-P) than in endoscopic mucosal resection (EMR) or endoscopic submucosal dissection. The mean procedure duration was significantly longer in the perforation group than in the no perforation group. On multivariate analysis, patient comorbidity and histologic grade of the lesion were significant independent risk factors for bleeding, whereas EMR-P was a significant independent risk factor for perforation after endoscopic resection.This study demonstrated that patient comorbidity and histologic grade of lesion were significant independent risk factors for bleeding, and EMR-P was a significant independent risk factor for perforation after endoscopic resection of colorectal LSTs.
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Affiliation(s)
| | - Sun-Seog Kweon
- Department of Preventive Medicine, Chonnam National University Medical School
| | - Jun Lee
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju
| | - Sang-Wook Kim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju
| | - Geom-Seog Seo
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
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15
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Risk factors of recurrence in T1 colorectal cancers treated by endoscopic resection alone or surgical resection with lymph node dissection. Int J Colorectal Dis 2018; 33:1029-1038. [PMID: 29748707 DOI: 10.1007/s00384-018-3081-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The recurrence of T1 colorectal cancers is relatively rare, and the prognostic factors still remain obscure. This study aimed to clarify the risk factors for recurrence in patients with T1 colorectal cancers treated by endoscopic resection (ER) alone or surgical resection (SR) with lymph node dissection, respectively. METHODS We reviewed 930 patients with resected T1 colorectal cancers (mean follow-up, 52.3 months). Patients were divided into two groups: those who underwent ER alone (298 cases), and those who underwent initial or additional SR with lymph node dissection (632 cases). Group differences in recurrence-free survival were evaluated using the Kaplan-Meier method and log-rank test. Associations between recurrence and clinicopathological features were evaluated in Cox regression analyses; hazard ratios (HRs) were calculated for the total population and each group. RESULTS Recurrence occurred in four cases (1.34%) in the ER group and six cases (0.95%) in the SR group (p = 0.32). Endoscopic resection, rectal location, and poor or mucinous (Por/Muc) differentiation were prognostic factors for recurrence in the total population. Por/Muc differentiation was prognostic factor in both groups. Female sex, depressed-type morphology, and lymphatic invasion were also prognostic factors in the ER group, but not in the SR group. CONCLUSIONS Endoscopic resection, rectal location, and Por/Muc differentiation are prognostic factors in the total population. For patients who undergo ER alone, female sex, depressed-type morphology, and lymphatic invasion are also risk factors for recurrence. For such patients, regional en-bloc surgery with lymph node dissection could reduce the risk of recurrence.
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16
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Daoud DC, Suter N, Durand M, Bouin M, Faulques B, von Renteln D. Comparing outcomes for endoscopic submucosal dissection between Eastern and Western countries: A systematic review and meta-analysis. World J Gastroenterol 2018; 24:2518-2536. [PMID: 29930473 PMCID: PMC6010943 DOI: 10.3748/wjg.v24.i23.2518] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 05/05/2018] [Accepted: 06/02/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare endoscopic submucosal dissection (ESD) outcomes between Eastern and Western countries. METHODS A systematic review and meta-analysis was performed using PubMed, MEDLINE, Web of Science, CINAHL and EBM reviews to identify studies published between 1990 and February 2016. The primary outcome was the efficacy of ESD based on information about either curative resection, en bloc or R0 resection rates. Secondary outcomes were complication rates, local recurrence rates and procedure times. RESULTS Overall, 238 publications including 84318 patients and 89512 gastrointestinal lesions resected using ESD were identified. 90% of the identified studies reporting ESD on 87296 lesions were conducted in Eastern countries and 10% of the identified studies reporting ESD outcomes in 2216 lesions were from Western countries. Meta-analyses showed higher pooled percentage of curative, en bloc, and R0 resection in the Eastern studies; 82% (CI: 81%-84%), 95% (CI: 94%-96%) and 89% (CI: 88%-91%) compared to Western studies; 71% (CI: 61%-81%), 85% (CI: 81%-89%) and 74% (CI: 67%-81%) respectively. The percentage of perforation requiring surgery was significantly greater in the Western countries (0.53%; CI: 0.10-1.16) compared to Eastern countries (0.01%; CI: 0%-0.05%). ESD procedure times were longer in Western countries (110 min vs 77 min). CONCLUSION Eastern countries show better ESD outcomes compared to Western countries. Availability of local ESD expertise and regional outcomes should be considered for decision making to treat gastrointestinal lesions with ESD.
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Affiliation(s)
- Dane Christina Daoud
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l’Université de Montréal (CHUM) and Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Nicolas Suter
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal (CHUM) and Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Madeleine Durand
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal (CHUM) and Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Mickael Bouin
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l’Université de Montréal (CHUM) and Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Bernard Faulques
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l’Université de Montréal (CHUM) and Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Daniel von Renteln
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l’Université de Montréal (CHUM) and Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
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17
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Urushibara F, Shiozawa E, Miyachi H, Misawa M, Cho T, Takehara Y, Arai N, Funaki T, Tazawa S, Homma M, Norose T, Omatsu M, Yamochi T, Kunimura T, Tate G, Honda K, Fumio I, Kudo SE, Takimoto M. Expression of matrix metalloproteinase-7 correlates with the invasion of T1 colorectal carcinoma. Oncol Lett 2018; 15:3614-3620. [PMID: 29456729 PMCID: PMC5795909 DOI: 10.3892/ol.2018.7746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 03/03/2017] [Indexed: 01/21/2023] Open
Abstract
T1 colorectal carcinomas (CRCs) are an initial site of metastatic spread. Various risk factors for lymph node metastasis have been investigated in T1 CRCs. However, the major step in the entire process of metastasis remains unclear. In terms of carcinoma invasion and metastasis, matrix metalloproteinases (MMPs) have recently gained increasing attention. Notably, MMP-7 is frequently overexpressed in CRCs, but its implication has not been determined in T1 CRCs yet. The present study aimed to clarify the associations between the pathological risk factors of T1 CRCs and MMP-7. In the current study, 211 lesions of T1 CRC that were resected endoscopically or surgically at Showa University Northern Yokohama Hospital (Yokohama, Japan) between April 2008 and December 2009 were retrospectively analyzed. MMP-7 was immunostained and evaluated by its frequency of expression. Pathological factors of T1 CRCs were analyzed in association with MMP-7 expression. Furthermore, the ultrastructural alterations of carcinoma invasion were examined using low vacuum-scanning electron microscopy (LV-SEM). MMP-7 expression was associated with venous invasion (P=0.005), and LV-SEM revealed the disappearance of the normal structure of collagen and elastic fibers of veins invaded by tumor cells expressing MMP-7. At the invasive front, MMP-7 has a vital role in carcinoma invasion, correlating with venous invasion of T1 CRCs.
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Affiliation(s)
- Fumihiko Urushibara
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Eisuke Shiozawa
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Tokyo 142-8555, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Tokyo 142-8555, Japan
| | - Tomonari Cho
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Yusuke Takehara
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Nana Arai
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Toshitaka Funaki
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Sakiko Tazawa
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Mayumi Homma
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Tomoko Norose
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Mutsuko Omatsu
- Department of Diagnostic Pathology, Showa University Northern Yokohama Hospital, Tokyo 142-8555, Japan
| | - Toshiko Yamochi
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Toshiaki Kunimura
- Department of Diagnostic Pathology, Showa University Northern Yokohama Hospital, Tokyo 142-8555, Japan
| | - Genshu Tate
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Ishida Fumio
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Tokyo 142-8555, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Tokyo 142-8555, Japan
| | - Masafumi Takimoto
- Department of Pathology, Showa University School of Medicine, Tokyo 142-8555, Japan
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Clinicopathological features of laterally spreading colorectal tumors and their association with advanced histology and invasiveness: An experience from Honam province of South Korea: A Honam Association for the Study of Intestinal Diseases (HASID). PLoS One 2017; 12:e0184205. [PMID: 28977010 PMCID: PMC5627894 DOI: 10.1371/journal.pone.0184205] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022] Open
Abstract
Background and aims Laterally spreading colorectal tumors (LSTs) are divided into four subtypes, including homogenous (HG), nodular mixed (NM), flat elevated (FE), and pseudo-depressed (PD), based on their different endoscopic morphologies. The aim of this study was to investigate the clinicopathological significance of LST subtypes and their association with advanced histology. Methods We investigated the medical records of consecutive patients with LST who initially underwent endoscopic resection at five university hospitals in Honam province of South Korea between January 2012 and December 2013. A total of 566LST lesions removed via endoscopic procedures were collected retrospectively for data analysis. Results The PD, FE, and NM subtypes were more common in the distal colon and the HG subtype in the proximal colon. The PD subtype had the biggest tumor size, followed by the NM subtype. The frequency of adenomatous pit pattern was significantly higher in the HG, NM, and FE subtypes than in the PD subtype. In contrast, the frequency of cancerous pit pattern was significantly higher in the PD subtype than in the other three subtypes. The rate of advanced histology (high-grade dysplasia or carcinoma) among the LSTs was 36.0%. The risk of advanced histology increased in the distal colon compared with the proximal colon. The PD subtype had the highest incidence of villous component, advanced histology,submucosal invasion, and postprocedure perforation among the four subtypes. The distal colon as tumor site, larger tumor size, PD subtype, and villous component were associated with a statistically significant increased risk of advanced histology. Conclusion Our results indicate that the location, size, endoscopic subtype, and histologic component of the LSTs are associated with an increased risk of advanced histology. Therefore, these clinicopathological parameters may be useful in selecting therapeutic strategies in the clinical setting.
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Saito Y, Bhatt A, Matsuda T. Colorectal endoscopic submucosal dissection and its journey to the West. Gastrointest Endosc 2017; 86:90-92. [PMID: 28610869 DOI: 10.1016/j.gie.2017.03.1548] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/30/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
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20
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Ichimasa K, Kudo SE, Miyachi H, Kouyama Y, Ishida F, Baba T, Katagiri A, Wakamura K, Hayashi T, Hisayuki T, Kudo T, Misawa M, Mori Y, Matsudaira S, Kimura Y, Kataoka Y. Patient gender as a factor associated with lymph node metastasis in T1 colorectal cancer: A systematic review and meta-analysis. Mol Clin Oncol 2017; 6:517-524. [PMID: 28413659 DOI: 10.3892/mco.2017.1172] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/11/2017] [Indexed: 12/27/2022] Open
Abstract
Approximately 10% of patients with T1 colorectal cancer have lymph node metastases (LNM), requiring node dissection along with surgical resection. Patient gender was recently reported to affect the occurrence of LNM. The aim of the present study was to assess whether patient gender was predictive of LNM in T1 colorectal cancer. Public databases, including PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched, using key terms related to 'T1 colorectal cancer' and 'lymph node'. All relevant studies reporting the adjusted odds ratio or risk ratio of LNM in relation to patient gender were included. The quality of the studies was classified according to the Quality in Prognostic Studies tool. A random-effects model was used and the quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. The initial database search identified 2,492 publications; of those, 36 studies reported unadjusted results. Of the 36 studies, 4 reported adjusted results and fulfilled the inclusion criteria for this meta-analysis: 3 studies were graded as having a moderate risk of bias, and 1 had a low risk of bias. The present meta-analysis demonstrated that female gender was associated with increased risk of LNM (risk ratio=2.45, 95% confidence interval: 1.03-3.88). The I2 statistic was 0.901, classified as very low (+OOO) and was downgraded by the risk of bias, inconsistency and publication bias. In conclusion, female gender was found to be correlated with LNM in patients with T1 colorectal cancer.
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Affiliation(s)
- Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yuta Kouyama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Toshiyuki Baba
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Atsushi Katagiri
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Kunihiko Wakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Tomokazu Hisayuki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Shingo Matsudaira
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yui Kimura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yuki Kataoka
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-8550, Japan
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21
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Bianco F, De Franciscis S, Belli A, Falato A, Fusco R, Altomare DF, Amato A, Asteria CR, Avallone A, Binda GA, Boccia L, Buzzo P, Carvello M, Coco C, Delrio P, De Nardi P, Di Lena M, Failla A, La Torre F, La Torre M, Lemma M, Luffarelli P, Manca G, Maretto I, Marino F, Muratore A, Pascariello A, Pucciarelli S, Rega D, Ripetti V, Rizzo G, Serventi A, Spinelli A, Tatangelo F, Urso EDL, Romano GM. T1 colon cancer in the era of screening: risk factors and treatment. Tech Coloproctol 2017; 21:139-147. [DOI: 10.1007/s10151-017-1586-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/03/2016] [Indexed: 02/07/2023]
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Kim B, Choi AR, Park SJ, Cheon JH, Kim TI, Kim WH, Hong SP. Long-Term Outcome and Surveillance Colonoscopy after Successful Endoscopic Treatment of Large Sessile Colorectal Polyps. Yonsei Med J 2016; 57:1106-14. [PMID: 27401640 PMCID: PMC4960375 DOI: 10.3349/ymj.2016.57.5.1106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 12/20/2015] [Accepted: 12/22/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Although there is a consensus about the need for surveillance colonoscopy after endoscopic resection, the interval remains controversial for large sessile colorectal polyps. The aim of this study was to evaluate the long-term outcome and the adequate surveillance colonoscopy interval required for sessile and flat colorectal polyps larger than 20 mm. MATERIALS AND METHODS A total of 204 patients with large sessile and flat polyps who received endoscopic treatment from May 2005 to November 2011 in a tertiary referral center were included. RESULTS The mean age was 65.1 years and 62.7% of the patients were male. The mean follow-up duration was 44.2 months and the median tumor size was 25 mm. One hundred and ten patients (53.9%) received a short interval surveillance colonoscopy (median interval of 6.3 months with range of 1-11 months) and 94 patients (46.1%) received a long interval surveillance colonoscopy (median interval of 13.6 months with range of 12-66 months). There were 14 patients (6.9%) who had local recurrence at the surveillance colonoscopy. Using multivariate regression analysis, a polyp size greater than 40 mm was shown to be independent risk factor for local recurrence. However, piecemeal resection and surveillance colonoscopy interval did not significantly influence local recurrence. CONCLUSION Endoscopic treatment of large sessile colorectal polyps shows a favorable long-term outcome. Further prospective study is mandatory to define an adequate interval of surveillance colonoscopy.
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Affiliation(s)
- Bun Kim
- Department of Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Center for Cancer Prevention and Detection, National Cancer Center, Goyang, Korea
| | - A Ra Choi
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
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Miyachi H, Kudo SE, Ichimasa K, Hisayuki T, Oikawa H, Matsudaira S, Kouyama Y, Kimura YJ, Misawa M, Mori Y, Ogata N, Kudo T, Kodama K, Hayashi T, Wakamura K, Katagiri A, Baba T, Hidaka E, Ishida F, Kohashi K, Hamatani S. Management of T1 colorectal cancers after endoscopic treatment based on the risk stratification of lymph node metastasis. J Gastroenterol Hepatol 2016; 31:1126-32. [PMID: 26641025 DOI: 10.1111/jgh.13257] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/13/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Recent advances in endoscopic technology have allowed many T1 colorectal carcinomas to be resected endoscopically with negative margins. However, the criteria for curative endoscopic resection remain unclear. We aimed to identify risk factors for nodal metastasis in T1 carcinoma patients and hence establish the indication for additional surgery with lymph node dissection. METHODS Initial or additional surgery with nodal dissection was performed in 653 T1 carcinoma cases. Clinicopathological factors were retrospectively analyzed with respect to nodal metastasis. The status of the muscularis mucosae (MM grade) was defined as grade 1 (maintenance) or grade 2 (fragmentation or disappearance). The lesions were then stratified based on the risk of nodal metastasis. RESULTS Muscularis mucosae grade was associated with nodal metastasis (P = 0.026), and no patients with MM grade 1 lesions had nodal metastasis. Significant risk factors for nodal metastasis in patients with MM grade 2 lesions were attribution of women (P = 0.006), lymphovascular infiltration (P < 0.001), tumor budding (P = 0.045), and poorly differentiated adenocarcinoma or mucinous carcinoma (P = 0.007). Nodal metastasis occurred in 1.06% of lesions without any of these pathological factors, but in 10.3% and 20.1% of lesions with at least one factor in male and female patients, respectively. There was good inter-observer agreement for MM grade evaluation, with a kappa value of 0.67. CONCLUSIONS Stratification using MM grade, pathological factors, and patient sex provided more appropriate indication for additional surgery with lymph node dissection after endoscopic treatment for T1 colorectal carcinomas.
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Affiliation(s)
- Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Tomokazu Hisayuki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Hiromasa Oikawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shingo Matsudaira
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yuta Kouyama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yui Jennifer Kimura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Noriyuki Ogata
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kenta Kodama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kunihiko Wakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Atsushi Katagiri
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Toshiyuki Baba
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Eiji Hidaka
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kenichi Kohashi
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigeharu Hamatani
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.,Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
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Imai K, Hotta K, Yamaguchi Y, Kakushima N, Tanaka M, Takizawa K, Kawata N, Matsubayashi H, Shimoda T, Mori K, Ono H. Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training. Gastrointest Endosc 2016; 83:954-62. [PMID: 26297870 DOI: 10.1016/j.gie.2015.08.024] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 08/07/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The technical difficulties inherent in endoscopic submucosal dissection (ESD) for colorectal neoplasms may result in the failure of en bloc resection or perforation. The aim of this retrospective study was to assess the predictors of en bloc resection failure or perforation by using preoperatively available factors. METHODS Between September 2002 and March 2013, 716 colorectal ESDs in 673 consecutive patients were performed at a tertiary cancer center. Patient characteristics, tumor location, tumor type, colonoscopy-related factors, and endoscopist experience were assessed based on a prospectively recorded institutional ESD database. Logistic regression analysis was performed to identify predictors of failure of en bloc resection or perforations, with subgroup analyses of ESDs performed by endoscopists less experienced in colorectal ESD (<40 cases) and for colonic lesions only. RESULTS On multivariate analysis, independent predictors of failure of en bloc resection or perforations were the presence of fold convergence (odds ratio [OR] 4.4; 95% confidence interval [95% CI], 1.9-9.9), protruding type (OR 3.6; 95% CI, 1.8-7.1), poor endoscope operability (OR 3.5; 95% CI, 1.8-6.9), right-sided colonic lesions (OR 3.0; 95% CI, 1.5-6.3 vs rectal lesions), left-sided colonic lesions (OR 3.2; 95% CI, 1.7-6.3, vs rectal lesions), the presence of an underlying semilunar fold (OR 2.1; 95% CI, 1.3-3.6), and a less-experienced endoscopist (OR 2.1; 95% CI, 1.3-3.6). Among less-experienced endoscopists, colonic lesions were independent predictors (right-sided colonic lesions 8.1; 95% CI, 2.9-25.1; left-sided colonic lesions 8.1; 95% CI, 2.5-28.3 vs rectal lesions). For colonic lesions, the presence of fold convergence (OR 3.7; 95% CI, 1.6-8.6), poor endoscope operability (OR 3.6; 95% CI, 1.8-7.2), a less-experienced endoscopist (OR 3.0; 95% CI, 1.7-1.8), and the presence of an underlying semilunar fold (OR 2.7; 95% CI, 1.5-4.7) were identified predictors. CONCLUSION This study successfully identified predictors of en bloc resection failure or perforation. Understanding these indicators could help to accurately stratify lesions according to technical difficulty and to appropriately select endoscopists.
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Affiliation(s)
- Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Large Colorectal Lesions: Evaluation and Management. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:197-207. [PMID: 28868460 PMCID: PMC5580011 DOI: 10.1016/j.jpge.2016.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 01/04/2016] [Indexed: 02/07/2023]
Abstract
In the last years, a distinctive interest has been raised on large polypoid and non-polypoid colorectal tumors, and specially on flat neoplastic lesions ≥20 mm tending to grow laterally, the so called laterally spreading tumors (LST). Real or virtual chromoendoscopy, endoscopic ultrasound or magnetic resonance should be considered for the estimation of submucosal invasion of these neoplasms. Lesions suitable for endoscopic resection are those confined to the mucosa or selected cases with submucosal invasion ≤1000 μm. Polypectomy or endoscopic mucosal resection remain a first-line therapy for large colorectal neoplasms, whereas endoscopic submucosal dissection in high-volume centers or surgery should be considered for large LSTs for which en bloc resection is mandatory.
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Endoscopic submucosal dissection versus local excision for early rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2015; 20:1-9. [PMID: 26519288 DOI: 10.1007/s10151-015-1383-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/16/2015] [Indexed: 12/13/2022]
Abstract
Endoscopic submucosal dissection (ESD) and local excision (LE) are minimally invasive procedures that can be used to treat early rectal cancer. There are no current guidelines or consensus on the optimal treatment strategy for these lesions. A systematic review was conducted to compare the efficacy and safety of ESD and LE. A meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. To perform the statistical analysis, the odds ratio (OR) was used for categorical variables and the weighted mean difference (WMD) for continuous variables. Four studies, involving a total of 307 patients, were identified. The length of hospital stay was longer in the group of patients undergoing LE [weighted mean difference (WMD) -1.94; 95% CI -2.85 to -1.02; p < 0.0001]. The combined results of the individual studies showed no significant differences as regards en-bloc resection rate (OR 0.82; 95% CI 0.25-2.70; p = 0.74), R0 resection rate (OR 1.53; 95% CI 0.62-3.73; p = 0.35), overall complication rate (OR 0.67; 95% CI 0.26-1.69; p = 0.40), and tumor size (WMD 0.57; 95% CI -3.64 to 4.78; p = 0.79) between ESD and LE. When adopting the fixed effect model which takes into account the study size, ESD was associated with a lower recurrence rate than LE (OR 0.15; 95% CI 0.03-0.87; p = 0.03), while with the random-effect model the difference was not significant (OR 0.18; 95% CI 0.02-2.04; p = 0.17). Over the last decade improvements in technology have improved the technical feasibility of rectal ESD. In specialized centers with highly experienced endoscopists, ESD can provide high-quality en-bloc excision of rectal neoplasms equivalent to traditional local excision.
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Tanimoto MA, Guerrero ML, Morita Y, Aguirre-Valadez J, Gomez E, Moctezuma-Velazquez C, Estradas-Trujillo JA, Valdovinos MA, Uscanga LF, Fujita R. Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis. World J Gastrointest Endosc 2015; 7:417-428. [PMID: 25901222 PMCID: PMC4400632 DOI: 10.4253/wjge.v7.i4.417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To summarize the clinical impact of a formal training for the effectiveness and safety of endoscopic submucosal dissection for gastrointestinal cancer.
METHODS: We searched databases including PubMed, EMBASE and the Cochrane Library and Science citation Index updated to August 2014 to include eligible articles. In the Meta-analysis, the main outcome measurements were en bloc resection rate, local recurrence rate (R0) and the incidence of procedure-related complications (perforation, bleeding).
RESULTS: En bloc resection was high for both, dissecting stomach tumors with an overall percentage of 93.2% (95%CI: 90.5-95.8) and dissecting colorectal tumors with an overall percentage of 89.4% (95%CI: 85.1-93.7). Although the number of studies reporting R0 resection (the dissected specimen was revealed free of tumor in both vertical and lateral margins) was small, the overall estimates for R0 resection were 81.4% (95%CI: 72-90.8) for stomach and 85.9% (95%CI: 77.5-95.5) for colorectal tumors, respectively. The analysis showed that the percentage of immediate perforation and bleeding were very low; 4.96 (95%CI: 3.6-6.3) and 1.4% (95%CI: 0.8-1.9) for colorectal tumors and 3.1% (95%CI: 2.0-4.1) and 4.8% (95%CI: 2.8-6.7) for stomach tumors, respectively.
CONCLUSION: In order to obtain the same rate of success of the analyzed studies it is a necessity to create training centers in the western countries during the “several years” of gastroenterology residence first only to teach EGC diagnose and second only to train endoscopic submucosal dissection.
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Tanaka S, Saitoh Y, Matsuda T, Igarashi M, Matsumoto T, Iwao Y, Suzuki Y, Nishida H, Watanabe T, Sugai T, Sugihara KI, Tsuruta O, Hirata I, Hiwatashi N, Saito H, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for management of colorectal polyps. J Gastroenterol 2015; 50:252-60. [PMID: 25559129 DOI: 10.1007/s00535-014-1021-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/07/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recently in Japan, the morbidity of colorectal polyp has been increasing. As a result, a large number of cases of colorectal polyps that are diagnosed and treated using colonoscopy has now increased, and clinical guidelines are needed for endoscopic management and surveillance after treatment. METHODS Three committees [the professional committee for making clinical questions (CQs) and statements by Japanese specialists, the expert panelist committee for rating statements by the modified Delphi method, and the evaluating committee by moderators] were organized. Ten specialists for colorectal polyp management extracted the specific clinical statements from articles published between 1983 and September 2011 obtained from PubMed and a secondary database, and developed the CQs and statements. Basically, statements were made according to the GRADE system. The expert panel individually rated the clinical statements using a modified Delphi approach, in which a clinical statement receiving a median score greater than seven on a nine-point scale from the panel was regarded as valid. RESULTS The professional committee created 91CQs and statements for the current concept and diagnosis/treatment of various colorectal polyps including epidemiology, screening, pathophysiology, definition and classification, diagnosis, treatment/management, practical treatment, complications and surveillance after treatment, and other colorectal lesions (submucosal tumors, nonneoplastic polyps, polyposis, hereditary tumors, ulcerative colitis-associated tumor/carcinoma). CONCLUSIONS After evaluation by the moderators, evidence-based clinical guidelines for management of colorectal polyps have been proposed for 2014.
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Affiliation(s)
- Shinji Tanaka
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for management of colorectal polyps", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13 Ginza, Chuo, Tokyo, 104-0061, Japan,
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Santos CEOD, Malaman D, Carvalho TDS, Lopes CV, Pereira-Lima JC. Malignancy in large colorectal lesions. ARQUIVOS DE GASTROENTEROLOGIA 2015; 51:235-9. [PMID: 25296085 DOI: 10.1590/s0004-28032014000300013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 04/11/2014] [Indexed: 01/14/2023]
Abstract
CONTEXT The size of colorectal lesions, besides a risk factor for malignancy, is a predictor for deeper invasion objectives: To evaluate the malignancy of colorectal lesions ≥20 mm. METHODS Between 2007 and 2011, 76 neoplasms ≥20 mm in 70 patients were analyzed. RESULTS The mean age of the patients was 67.4 years, and 41 were women. Mean lesion size was 24.7 mm ± 6.2 mm (range: 20 to 50 mm). Half of the neoplasms were polypoid and the other half were non-polypoid. Forty-two (55.3%) lesions were located in the left colon, and 34 in the right colon. There was a high prevalence of III L (39.5%) and IV (53.9%) pit patterns. There were 72 adenomas and 4 adenocarcinomas. Malignancy was observed in 5.3% of the lesions. Thirty-three lesions presented advanced histology (adenomas with high-grade dysplasia or early adenocarcinoma), with no difference in morphology and site. Only one lesion (1.3%) invaded the submucosa. Lesions larger than 30 mm had advanced histology (P = 0.001). The primary treatment was endoscopic resection, and invasive carcinoma was referred to surgery. Recurrence rate was 10.6%. CONCLUSIONS Large colorectal neoplasms showed a low rate of malignancy. Endoscopic treatment is an effective therapy for these lesions.
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Affiliation(s)
| | - Daniele Malaman
- Departamento de Gastroenterologia e Endoscopia Digestiva, Hospital Santa Casa, Bagé, RS, Brasil
| | | | - César Vivian Lopes
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA, Porto Alegre, RS, Brasil
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Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms. Dig Dis Sci 2015; 60:211-6. [PMID: 25502119 DOI: 10.1007/s10620-014-3484-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD. METHODS There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS. RESULTS There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics. CONCLUSIONS The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.
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Hong MJ, Kim JH, Lee SY, Sung IK, Park HS, Shim CS. Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms. Dig Dis Sci 2015. [PMID: 25502119 DOI: 10.1007/s10620-014-3484-3489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD. METHODS There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS. RESULTS There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics. CONCLUSIONS The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.
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Affiliation(s)
- Mi Jin Hong
- Department of Internal Medicine, Digestive Disease Center, Konkuk University School of Medicine, Konkuk University Medical Center, 120-1 Neungdong-ro, Hwayang-dong, Gwangjin-gu, Seoul, 143-729, Korea
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Miyamoto H, Ikematsu H, Fujii S, Osera S, Odagaki T, Oono Y, Yano T, Ochiai A, Sasaki Y, Kaneko K. Clinicopathological differences of laterally spreading tumors arising in the colon and rectum. Int J Colorectal Dis 2014; 29:1069-75. [PMID: 24986136 DOI: 10.1007/s00384-014-1931-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Laterally spreading tumors (LST) have been recognized worldwide. The aim of our retrospective study was to evaluate the clinicopathological differences of LST arising in the colon and rectum. METHODS We investigated the clinical records of consecutive patients with LST that were endoscopically or surgically resected at our hospital between February 2006 and March 2011. LST were classified into three types: granular-homogenous (LST-GH), granular-nodular mixed (LST-GM), and nongranular (LST-NG) types. We also defined the hardly elevated flat lesion with a dilated pit pattern that occurs at the margins of LST as the "skirt." The clinicopathological characteristics of the LST arising in the colon and rectum, including the presence of the skirt, were compared. RESULTS A total of 496 colorectal LST in 435 patients were examined. LST-GM was predominant in the rectum, whereas LST-NG was predominant in the colon (p < 0.001). The mean tumor size was larger in the rectum (39.3 ± 17.9 mm) than the colon (25.8 ± 13.6 mm) (p < 0.001). Low-grade dysplasia frequency was lower in the rectum than the colon (4 vs. 37%, p < 0.001). The skirt was identified in 15 lesions (3.0%), with a higher incidence in the rectum than the colon (17 vs. 0.5%, p < 0.001). The skirt was found only in LST-GM. CONCLUSIONS A greater proportion of LST-GM, greater mean size, and lower incidence of low-grade dysplasia were found in rectal LST. The skirt was a novel and unique finding, primarily observed in rectal LST-GM cases.
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Affiliation(s)
- Hideaki Miyamoto
- Department of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa City, Chiba, 277-8577, Japan
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Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection. BIOMED RESEARCH INTERNATIONAL 2014; 2014:925058. [PMID: 24877148 PMCID: PMC4022075 DOI: 10.1155/2014/925058] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/11/2014] [Accepted: 04/14/2014] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for colorectal cancer. However, due to technical difficulties and an increased rate of complications, ESD is not widely used in the colorectum. In some cases, endoscopic treatment alone is insufficient for disease control, and laparoscopic surgery is required. The combination of laparoscopic surgery and endoscopic resection represents a new frontier in cancer treatment. Recent developments in advanced polypectomy and minimally invasive surgical techniques will enable surgeons and endoscopists to challenge current practice in colorectal cancer treatment. Endoscopic full-thickness resection (EFTR) of the colon offers the potential to decrease the postoperative morbidity and mortality associated with segmental colectomy while enhancing the diagnostic yield compared to current endoscopic techniques. However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES). Innovative methods and new devices for EFTR and suturing are being developed and may potentially change traditional paradigms to achieve minimally invasive surgery for colorectal cancer. The present paper aims to discuss the complementary role of ESD and the future development of EFTR. We focus on the possibility of achieving EFTR using the ESD method and closing devices.
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Saito Y, Sakamoto T, Nakajima T, Matsuda T. Colorectal ESD: current indications and latest technical advances. Gastrointest Endosc Clin N Am 2014; 24:245-55. [PMID: 24679235 DOI: 10.1016/j.giec.2013.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The number of medical facilities that perform colorectal endoscopic submucosal dissection (ESD) has been growing, and its effectiveness has been increasingly reported in recent years. Indications approved by the Japanese government's medical insurance system are early colorectal cancers with a maximum tumor size of 2-5 cm. ESD was an effective procedure for treating noninvasive colorectal tumors difficult to resect en bloc by conventional EMR, resulting in a higher en bloc resection rate that is less invasive than surgery. Based on the excellent clinical results of colorectal ESDs, the Japanese health care insurance system has approved colorectal ESD for coverage.
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Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Takeshi Nakajima
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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Should laterally spreading tumors granular type be resected en bloc in endoscopic resections? Surg Endosc 2014; 28:2167-73. [DOI: 10.1007/s00464-014-3449-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023]
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Saito Y, Yamada M, So E, Abe S, Sakamoto T, Nakajima T, Otake Y, Ono A, Matsuda T. Colorectal endoscopic submucosal dissection: Technical advantages compared to endoscopic mucosal resection and minimally invasive surgery. Dig Endosc 2014; 26 Suppl 1:52-61. [PMID: 24191896 DOI: 10.1111/den.12196] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 09/25/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In recent years, the effectiveness of colorectal endoscopic submucosal dissection (ESD) has been increasingly reported. Herein, we highlight the most recent developments and technical advantages of colorectal ESD compared to EMR and minimally invasive surgery. METHODS All candidate lesions for ESD were confirmed as being intramucosal tumors by colonoscopy. Presently, the indications for colorectal ESD approved by the Japanese government's medical insurance system are early colorectal cancers with a maximum tumor size of 2-5 cm; however, many early cancers >5 cm have been treated by ESD in referral centers. RESULTS The primary advantage of ESD compared to endoscopic mucosal resection (EMR) is a higher en-bloc resection rate for large colonic tumors that had previously been treated by surgery. ESD has several advantages compared to other therapeutic modalities, such as being a safer technique and providing better quality of life. For rectal cancer treatment, a longer procedure time is required for laparoscopic assisted colectomy, whereas trans-anal resection and trans-anal endoscopic microsurgery are more invasive than ESD with a significantly higher recurrence rate. Accordingly, ESD is the preferred choice for early colorectal cancers when there is no risk of lymph-node metastasis. CONCLUSION ESD is an effective procedure for treating non-invasive non-polypoid colorectal tumors. These tumors may be difficult to resect en bloc by conventional EMR. The use of ESD results in a higher en-bloc resection rate and is less invasive than surgery.
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Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Endoscopic submucosal dissection for nonpedunculated submucosal invasive colorectal cancer: is it feasible? Eur J Gastroenterol Hepatol 2013; 25:1051-9. [PMID: 23660936 DOI: 10.1097/meg.0b013e328361dd39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS There have been no definite indications for additional surgical resection after endoscopic submucosal dissection (ESD) of submucosal invasive colorectal cancer (SICC). The aims of this study were to evaluate the feasibility of ESD for nonpedunculated SICC and to determine the need for subsequent surgery after ESD. PATIENTS AND METHODS A total of 150 patients with nonpedunculated SICC in resected specimens after ESD were analyzed. Among them, 75 patients underwent subsequent surgery after ESD. Clinical outcomes of ESD and histopathological risk factors for lymph node (LN) metastasis were evaluated. RESULTS The en-bloc resection and complete resection (R0) rates of ESD were 98% (147/150) and 95.3% (143/150), respectively. None of the patients had delayed bleeding after ESD. Perforations occurred in seven patients (4.7%), which were successfully treated by endoscopic clipping. After subsequent surgery for 75 patients, LN metastases were found in 10 cases (13.3%). The incidence of LN metastasis was significantly higher in tumors featuring submucosal invasion of at least 1500 μm, lymphovascular invasion, and tumor budding. Multivariate analysis showed that lymphovascular invasion (P=0.034) and tumor budding (P=0.015) were significantly associated with LN metastasis. Among the 150 patients, no local recurrence or distant metastasis was detected, except one patient with risk factors and who refused subsequent surgery, during the overall median follow-up of 34 months (range, 5-63 months). CONCLUSION ESD is feasible and may be considered as an alternative treatment option for carefully selected cases of nonpedunculated SICC, provided that the appropriate histopathological curative criteria are fulfilled in completely resectable ESD specimens.
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Coman RM, Gotoda T, Draganov PV. Training in endoscopic submucosal dissection. World J Gastrointest Endosc 2013; 5:369-378. [PMID: 23951392 PMCID: PMC3742702 DOI: 10.4253/wjge.v5.i8.369] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 04/26/2013] [Accepted: 06/19/2013] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.
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Abstract
Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient's quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee's background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.
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Affiliation(s)
- Roxana M Coman
- Roxana M Coman, Peter V Draganov, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Gainesville, FL 32610, United States
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Uraoka T, Parra-Blanco A, Yahagi N. Colorectal endoscopic submucosal dissection: is it suitable in western countries? J Gastroenterol Hepatol 2013; 28:406-14. [PMID: 23278302 DOI: 10.1111/jgh.12099] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 12/14/2022]
Abstract
Endoscopic submucosal dissection (ESD) represents a significant advance in therapeutic endoscopy with the major advantage being the ability to achieve a higher en bloc resection rate for early stage lesions. Western endoscopists infrequently perform colorectal ESD (CR-ESD) because of the greater technical difficulty involved, longer procedure times, and increased risk of perforation. Specialized training and sufficient clinical experience are necessary to successfully perform ESDs, but a systematic education and training program has still not been established in Japan or elsewhere in the world. Experts generally acknowledge that the stomach is the first organ in which endoscopists should begin performing ESDs. The incidence and detection rates for early stage gastric cancer are significantly higher in Japan than in western countries, so Japanese endoscopists have a greater opportunity to perform gastric ESDs than their western counterparts. It is logical to ask, therefore, whether CR-ESD can be effectively applied in western countries. Based on a review of the relevant literature and our practical perspective, we have focused on the progress made in performing CR-ESD, its indications, training methods, and learning curve. Use of animal gastric and colon models is strongly recommended along with accumulating the necessary experience from the rectum to the colon on a step-by-step basis. It is reasonable to assume that an increasing number of CR-ESDs will be performed by western endoscopists in the foreseeable future given the continuing development of new techniques, and the refinement of instruments and other technologically advanced devices together with the creation of even more effective submucosal injection agents.
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Affiliation(s)
- Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan.
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Saito Y, Otake Y, Sakamoto T, Nakajima T, Yamada M, Haruyama S, So E, Abe S, Matsuda T. Indications for and technical aspects of colorectal endoscopic submucosal dissection. Gut Liver 2013; 7:263-9. [PMID: 23710305 PMCID: PMC3661956 DOI: 10.5009/gnl.2013.7.3.263] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 10/08/2012] [Accepted: 10/08/2012] [Indexed: 12/15/2022] Open
Abstract
Due to the widespread acceptance of gastric and esophageal endoscopic submucosal dissections (ESDs), the number of medical facilities that perform colorectal ESDs has grown and the effectiveness of colorectal ESD has been increasingly reported in recent years. The clinical indications for colorectal ESD at the National Cancer Center Hospital, Tokyo, Japan include laterally spreading tumor (LST) nongranular type lesions >20 mm and LST granular type lesions >30 mm. In addition, 0-IIc lesions >20 mm, intramucosal tumors with nonlifting signs and large sessile lesions, all of which are difficult to resect en bloc by conventional endoscopic mucosal resection (EMR), represent potential candidates for colorectal ESD. Rectal carcinoid tumors less than 1 cm in diameter can be treated simply, safely, and effectively by endoscopic submucosal resection using a ligation device and are therefore not indications for ESD. The en bloc resection rate was 90%, and the curative resection rate was 87% for 806 ESDs. The median procedure time was 60 minutes, and the mean size for resected specimens was 40 mm (range, 15 to 150 mm). Perforations occurred in 23 (2.8%) cases, and postoperative bleeding occurred in 15 (1.9%) cases, but only two perforation cases required emergency surgery (0.25%). ESD was an effective procedure for treating colorectal tumors that are difficult to resect en bloc by conventional EMR. ESD resulted in a higher en bloc resection rate as well as decreased invasiveness in comparison to surgery. Based on the excellent clinical results of colorectal ESDs in Japan, the Japanese healthcare insurance system has approved colorectal ESD for coverage.
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Affiliation(s)
- Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Endoscopic submucosal dissection for colorectal tumors—1,000 colorectal ESD cases: one specialized institute’s experiences. Surg Endosc 2012; 27:31-9. [DOI: 10.1007/s00464-012-2403-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 05/17/2012] [Indexed: 12/12/2022]
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Risk factors for postoperative recurrence in patients with pathologically T1 colorectal cancer. World J Surg 2012; 36:424-30. [PMID: 22187130 DOI: 10.1007/s00268-011-1378-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The evolution of diagnostic procedures has resulted in an increase in early detection of pathologically T1 (pT1) colorectal cancer (CRC). However, the risk factors affecting long-term outcomes of patients with pT1 CRCs have been unclear. The aim of the present study was to identify risk factors for postoperative recurrence and overall survival in patients with pT1 CRC. METHODS Between January 1990 and January 2003, a total of 284 patients with pT1 CRC underwent radical surgery in the authors' institution. The impact of clinicopathological factors on postoperative recurrence and overall survival was estimated by univariate and multivariate analysis. RESULTS The median follow-up period was 55 months (interquartile range: 47.1 months). Postoperative recurrence occurred in 8 (2.8%) patients. The overall 5-year and 10-year disease-free survival rates were 98.4 and 92.7%. Multivariate analysis showed the presence of lymphatic invasion only was an independent risk factor for postoperative recurrence in pT1 CRC patients (hazard ratio: 11.622; P = 0.003). The 5-year and 10-year disease-free survival rates of the patients in N-ly- group, the N-ly + group, and the N+ group were 99.5%/98.2% and 96.3%/75.2%, and 93.3%/93.3%, respectively. Additionally, 4 of the 8 recurrences were found more than 5 years after the operation. CONCLUSIONS Lymphatic invasion was an independent risk factor for recurrence in pT1 CRC patients.
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Kobayashi N, Yoshitake N, Hirahara Y, Konishi J, Saito Y, Matsuda T, Ishikawa T, Sekiguchi R, Fujimori T. Matched case-control study comparing endoscopic submucosal dissection and endoscopic mucosal resection for colorectal tumors. J Gastroenterol Hepatol 2012; 27:728-33. [PMID: 22004124 DOI: 10.1111/j.1440-1746.2011.06942.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM For large colorectal tumors, the en bloc resection rate achieved by endoscopic mucosal resection (EMR) is insufficient, and this leads to a high rate of local recurrence. As endoscopic submucosal dissection (ESD) has been reported to achieve a higher rate of en bloc resection and a lower rate of local recurrence in the short-term, it is expected to overcome the limitations of EMR. We conducted a matched case-control study between ESD and EMR to clarify the effectiveness of ESD for colorectal tumors. METHODS Between April 2005 and February 2009, a total of 28 colorectal tumors in 28 patients were resected by ESD and were followed up by colonoscopy at least once. As a control group, 56 EMR cases from our prospectively completed database were matched. En bloc resection, complication and recurrence rates were compared between the two groups. RESULTS The mean sizes of the lesions were 27.1 mm in the ESD group and 25.0 mm in the EMR group. The en bloc resection rate was significantly higher in the ESD group (92.9% vs 37.5% with ESD vs EMR), and the rate of perforation was also significantly higher (10.7% vs 0%). All cases of perforation were managed conservatively. No recurrence was observed in the ESD group, whereas local recurrences were detected in 12 EMR cases (21.4%). Eleven of the 12 recurrences (91.7%) were managed endoscopically, and one required surgical resection. CONCLUSIONS Endoscopic submucosal dissection is a promising technique for the treatment of colorectal tumors, giving an excellent outcome in comparison with EMR.
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Affiliation(s)
- Nozomu Kobayashi
- Department of Diagnostic Imaging, Tochigi Cancer Center, Utsunomiya, Tochigi, Japan.
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Otake Y, Saito Y, Sakamoto T, Aoki T, Nakajima T, Toyoshima N, Matsuda T, Ono H. New closure technique for large mucosal defects after endoscopic submucosal dissection of colorectal tumors (with video). Gastrointest Endosc 2012; 75:663-7. [PMID: 22341112 DOI: 10.1016/j.gie.2011.10.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/26/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Certain large colorectal tumors satisfy expanded indications for endoscopic submucosal dissection (ESD); however, the resulting large mucosal defects may contribute to complications such as delayed bleeding and perforation. Various closure devices and methods have been developed for large mucosal defects to prevent such complications. OBJECTIVE To demonstrate the feasibility of a new and simple technique for closing large mucosal defects after colorectal ESD. DESIGN Pilot feasibility study. SETTING Single center. PATIENTS Ten patients with 10 tumors half circumferential or less in size with sufficient muscle layer exposure after ESD were selected and treated by using the closure technique between July 2009 and June 2010. INTERVENTION Small mucosal incisions were made around the mucosal defect by the same needle-knife used during ESD. These incisions provided a better grip for conventional clips, which then facilitated lifting the surrounding mucosa across the defect without slipping, thereby making it considerably easier to reduce the size of the defect and place additional clips. MAIN OUTCOME MEASUREMENTS Patient characteristics and tumor clinicopathologic features were assessed as well as closure completion rate, closure procedure time, and closure-related complications. RESULTS All 10 tumors were successfully treated by ESD. Mean lesion size was 26.8 mm (range 8-50 mm). All mucosal defects were completely closed by using the new closure technique, without complications. Mean closure procedure time was 15 minutes (range 8-35 minutes). LIMITATIONS Small sample size with specifically selected patients. CONCLUSION Large mucosal defects resulting from colorectal ESD can be completely closed with small mucosal incisions by using conventional clips.
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Affiliation(s)
- Yosuke Otake
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Hotta K, Saito Y, Fujishiro M, Ikehara H, Ikematsu H, Kobayashi N, Sakamoto N, Takeuchi Y, Uraoka T, Yamaguchi Y. Impact of endoscopic submucosal dissection for the therapeutic strategy of large colorectal tumors. J Gastroenterol Hepatol 2012; 27:510-5. [PMID: 21916993 DOI: 10.1111/j.1440-1746.2011.06926.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The change of therapeutic strategy for large colorectal tumors after the introduction of endoscopic submucosal dissection (ESD) has not yet been clarified. The aim of this study was to estimate the impact of ESD as an initial treatment strategy. METHODS A questionnaire was administered to nine expert panelists in colorectal ESD. The questionnaire used retrospective data from consecutive case series. Forty-seven cases of early colorectal tumors (≥ 20 mm) were included. Endoscopic growth types were 25 laterally-spreading tumors (LST) of granular type (G), 15 LST of non-granular types (NG), and seven protruded types. Pathological diagnoses included 15 adenomas (Ad), 18 intramucosal cancers (M), three submucosally-shallow invasive cancers (< 1000 µm) (SMs), and 11 submucosally-deep invasive cancers (≥ 1000 µm) (SMd). The expert panelists completed questionnaires about recommended initial treatment under suppositions of before and after the introduction of ESD. Over-surgery was defined as surgery for Ad, M, and SMs. Non-curative endoscopic resection (ER) was defined as ER for SMd. RESULTS After the introduction of ESD, the reduction in the over-surgery rate was estimated at 10.8% for Ad, M, and SMs, and the increase in the non-curative ER rate was estimated at 27.2% for SMd. By endoscopic growth type, the reduction of over-surgery rates for LST-NG, LST-G, and protruded type was 15.5%, 10.5%, and 2.2%, respectively. CONCLUSIONS The endoscopists changed their therapeutic strategy for large colorectal tumors to reduce over-surgery, especially in LST-NG, demonstrating the impact of ESD.
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Affiliation(s)
- Kinichi Hotta
- Department of Gastroenterology, Saku Central Hospital, Saku, Japan.
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Endoscopic treatment of large colorectal tumors: comparison of endoscopic mucosal resection, endoscopic mucosal resection-precutting, and endoscopic submucosal dissection. Surg Endosc 2012; 26:2220-30. [PMID: 22278105 DOI: 10.1007/s00464-012-2164-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 01/04/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a useful therapeutic technique for colorectal tumors. However, for tumors larger than 20 mm, the chance of piecemeal resection is high. Recently introduced endoscopic submucosal dissection (ESD) enables en bloc resection regardless of the tumor size. This study aimed to compare the effectiveness and outcomes of EMR, EMR-precutting (EMR-P), and ESD in the treatment of colorectal tumors 20 mm in size or larger. METHODS This study reviewed 523 nonpedunculated colorectal tumors (499 patients) 20 mm or larger that received endoscopic treatment (EMR in 140 cases, EMR-P in 69 cases, and ESD in 314 cases) from January 2004 to November 2009. RESULTS The mean sizes of the tumors were 21.7 ± 3.5 mm (EMR), 23.5 ± 5.6 mm (EMR-P), and 28.9 ± 12.7 mm (ESD). The ratios of adenocarcinomas were 15.7% (EMR), 29% (EMR-P), and 37.9% (ESD). The en bloc resection rates were 42.9% (EMR), 65.2% (EMR-P), and 92.7% (ESD), and the complete resection rates were 32.9% (EMR), 59.4% (EMR-P), and 87.6% (ESD). Perforation occurred in 2.9% of the EMR-P cases and 8% of the ESD cases. The recurrence rates were 25.9% (EMR; median follow-up period, 26 months), 3.2% (EMR-P; median follow-up period, 16 months), and 0.8% (ESD; median follow-up period, 17 months). CONCLUSION For the treatment of large, nonpedunculated colorectal tumors, ESD is more effective than either EMR or EMR-P. Although ESD is technically demanding, it has clinical significance by overcoming the limitations of both EMR and EMR-P.
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Santos CEOD, Malaman D, Pereira-Lima JC. Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas. ARQUIVOS DE GASTROENTEROLOGIA 2011; 48:242-7. [DOI: 10.1590/s0004-28032011000400005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 07/14/2011] [Indexed: 02/07/2023]
Abstract
CONTEXT: Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. OBJECTIVES: To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. METHODS: A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique. Complications and recurrence were analyzed. Patients were followed up for 18 months. RESULTS: There were 83 (48.2%) superficial lesions, 57 (33.1%) depressed lesions, 44 (25.6%) laterally spreading tumors, and 45 (26.2%) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0%) lesions were located in the rectum, 68 (39.5%) in the left colon, and 80 (46.5%) in the right colon (transverse, ascending, and cecum). There were 167 (97.1%) neoplasms: 142 (82.5%) adenomatous lesions, 24 (14.0%) intramucosal carcinomas, and 1 (0.6%) invasive carcinoma. En bloc resection was performed in 158 (91.9%) cases and piecemeal resection in 14 (8.1%). Bleeding occurred in 5 (2.9%) cases. Recurrence was observed in 4.1% (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). CONCLUSIONS: Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.
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Motohashi O. Two-point fixed endoscopic submucosal dissection in rectal tumor (with video). Gastrointest Endosc 2011; 74:1132-6. [PMID: 21944316 DOI: 10.1016/j.gie.2011.07.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 07/18/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Polypectomy, EMR, transanal endoscopic microsurgery, and surgery have been performed as treatments of rectal tumors. Endoscopic procedures are the least-invasive treatments for patients. Complete resection of the lesion is required to prevent its recurrence, and endoscopic submucosal dissection (ESD) has begun to be performed. With increasing requirements for safety, reliability, and simplicity in ESD, we decided to use a 2-point fixed ESD with a transparent hood fitted with a mucosal forceps channel in a case of a rectal tumor and report its usefulness. OBJECTIVE To evaluate the safety, simplicity, and usefulness of 2-point fixed ESD performed on a rectal tumor. DESIGN Case series. SETTING Kanagawa Cancer Center Hospital. MAIN OUTCOME MEASUREMENTS Safety, simplicity, and usefulness of 2-point fixed ESD performed on a rectal tumor. RESULTS The mean duration of the procedure was 45 minutes (range 30-110 minutes). Hemostasis and manipulation of the vessels were easy in all patients who did not have postoperative bleeding, perforation, or retroperitoneal emphysema as complications. LIMITATIONS Uncontrolled study. CONCLUSION This study of 2-point ESD performed in 12 patients with rectal lesions revealed that the 2-point ESD with a transparent hood fitted with a mucosal forceps channel is a useful auxiliary device, enabling safe and reliable ESD on a rectal lesion.
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Affiliation(s)
- Osamu Motohashi
- Department of Gastroenterology, Kanagawa Cancer Center, Kanagawa, Japan
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Kaji E, Kato J, Suzuki H, Akita M, Horii J, Saito S, Higashi R, Ishikawa S, Kuriyama M, Hiraoka S, Uraoka T, Yamamoto K. Analysis of K-ras, BRAF, and PIK3CA mutations in laterally-spreading tumors of the colorectum. J Gastroenterol Hepatol 2011; 26:599-607. [PMID: 21332555 DOI: 10.1111/j.1440-1746.2010.06485.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Laterally-spreading tumors (LST) are a newly-recognized category of colorectal neoplasia, and are defined as lesions larger than 10 mm in diameter and extending circumferentially rather than vertically. However, genetic features of this new category of tumors are not fully elucidated. The aim of this study was to evaluate genetic alterations in LST. METHODS We examined K-ras, BRAF, and phosphoinositide-3-kinase catalytic-α polypeptide (PIK3CA) mutations in 101 LST, including 68 LST-granular type (LST-G) and 33 LST-non-granular type by direct sequencing. As controls, we examined these gene mutations in 66 protruded colon adenomas (10 mm or larger) and 44 advanced colon cancers. RESULTS K-ras, BRAF, and PIK3CA mutations were observed in 59 (58%), zero (0%), and three (3%) LST, respectively. LST-G morphology in the right-sided colon was significantly correlated with the existence of K-ras mutations, whereas a size of 20 mm or larger was the only predictor of mutations in the left-sided colorectum. The frequency of K-ras mutations in LST was particularly marked in the left-sided colorectum compared to protruded adenomas or advanced cancers (LST vs protruded adenomas, P < 0.001; LST vs advanced cancers, P = 0.002), whereas in the right-sided colon, K-ras mutations were equally frequent. PIK3CA mutations were not familiar in either LST (3%) or advanced cancers (9%). CONCLUSIONS K-ras mutations were involved in colorectal LST in different manners according to tumor location.
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Affiliation(s)
- Eisuke Kaji
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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