Implementation of endoscopic submucosal dissection for early colorectal neoplasms in Sweden. Gastroenterol Res Pract. 2013;2013:758202. [PMID: 23935611 PMCID: PMC3712201 DOI: 10.1155/2013/758202]

Cost comparisons of endoscopic and surgical resection of stage T1 rectal cancer

Background and study aims  Management of T1 rectal cancer is complex and includes several resection methods, making cost comparisons challenging. The aim of this study was to compare costs of endoscopic and surgical resection and to investigate hypothetical cost scenarios for the treatment of T1 rectal cancer. Patients and methods  Retrospective population-based cost minimization study on prospectively collected data on T1 rectal cancer patients treated using endoscopic submucosal dissection (ESD), transanal endoscopic microsurgery (TEM), open, laparoscopic, or robotic resection, in Skåne County, Sweden (2011-2017). The hypothetical cost scenarios were based on the distribution of high-risk features of lymph node metastases in a national cohort (2009-2017). Results  Eighty-five patients with T1 RC undergoing ESD (n = 16), TEM (n = 17), open (n = 35), laparoscopic (n = 9), and robotic (n = 8) resection were included. ESD had a total 1-year cost of 5165 € and was significantly ( P  < 0.05) less expensive compared to TEM (14871€), open (21 453 €), laparoscopic (22 488 €) and robotic resection (26 562 €). Risk factors for lymph node metastases were seen in 68 % of 779 cases of T1 rectal cancers included in the national cohort. The hypothetical scenario of performing ESD on all T1 RC had the lowest total 1-year per patient cost compared to all other alternatives. Conclusions  This is the first study analyzing total 1-year costs of endoscopic and surgical methods to resect T1 rectal cancer, which showed that the cost of ESD was significantly lower compared to TEM and surgical resection. In fact, based on hypothetical cost scenarios, ESD is still justifiable from a cost perspective even when all high-risk cases are followed by surgery in accordance to guidelines.

Feasibility and learning curve of unsupervised colorectal endoscopic submucosal hydrodissection at a Western Center

OBJECTIVES

Colorectal endoscopic submucosal dissection (CR-ESD) is an evolving technique in Western countries. We aimed to determine the results of the untutored implementation of endoscopic submucosal hydrodissection for the treatment of complex colorectal polyps and establish the learning curve for this technique.

METHODS

This study included data from 80 consecutive CR-ESDs performed by a single unsupervised western therapeutic endoscopist. To assess the learning curve, procedures were divided into four groups of 20 each.

RESULTS

En bloc resection was achieved in 55, 75, 75 and 95% cases in the consecutive time periods (period 1 vs. 4, P = 0.003). Curative resection was achieved in 55, 75, 70 and 95%, respectively (P = 0.037). Overall, series results demonstrated R0 resection in 75% of cases, with 23.7% requiring conversion to endoscopic piecemeal mucosal resection, and 1.25% incomplete resections. Complications included perforations (7.5%) and bleeding (3.7%). Multivariate analysis revealed factors more likely to result in association with non en bloc vs. En bloc resection, where polyp size ≥35 mm [70 vs. 23.4%; odds ratio (OR) 13.2 (1.7-100.9); P = 0. 013], severe fibrosis [40 vs. 11.7%; OR 10.2 (1.2-86.3); P = 0.033] and where carbon dioxide for insufflation was not used [65 vs. 30%; OR 0.09 (0.01-0.53); P = 0.008].

CONCLUSION

CR-ESD by hydrodissection has good safety and efficacy profile and offers well tolerated and effective treatment for complex polyps. As such, this technique may be useful in the West, in centers, where previous gastric ESD is not frequent or Japanese mentoring is not possible.

EndoClot®SIS Polysaccharide Injection as a Submucosal Fluid Cushion for Endoscopic Mucosal Therapies: Results of Ex Vivo and In Vivo Studies

BACKGROUND

There are many studies on submucosal injection materials, but their clinical use is restricted for various reasons. The objective of this study was to compare the feasibility and safety of injected EndoClot^®SIS polysaccharide as a submucosal injection material (SFC) in ESD in the pig stomach to that of injected sigMAVisc™ or Eleview™.

METHODS

Four pig stomachs were used for the ex vivo study. Eighteen pigs were used for the in vivo study. In the ex vivo study, four injections were made in the gastric submucosa to induce submucosal uplift and extend its duration. Tissue change was observed. The in vivo study was performed in 2 steps. First, 3 injections were made in the esophageal mucosa to induce submucosal uplift and extend its duration. Histological change was observed. Second, ESD was performed in the stomach by injecting EndoClot^®SIS polysaccharide, sigMAVisc™, or Eleview™ (each, n = 6) as an SFC. The effects of these agents on wound healing were examined. We evaluated the efficacy and safety of endoscopic surgery after EndoClot^®SIS polysaccharide injection.

RESULTS

EndoClot^®SIS polysaccharide produced a longer-lasting elevation with clearer margins than was achieved by sigMAVisc™, Eleview™, or 0.9% NaCl and thereby enabled precise ESD without complications, such as bleeding and perforation. No obvious histopathological damage was observed at the injection site on endoscopy and histology.

CONCLUSION

Submucosally injected EndoClot^®SIS polysaccharide increased the effective separation of the mucosa and submucosa and reduced surgical complications. Hence, EndoClot^®SIS polysaccharide injection is a safe and effective submucosal injection material.

European experience of colorectal endoscopic submucosal dissection: a systematic review of clinical efficacy and safety

BACKGROUND

Endoscopic submucosal dissection (ESD) is an advanced method allowing en bloc resection of large and complex lesions in colon and rectum. Herein, the European experience of colorectal ESD was systematically reviewed in the medical literature to determine the clinical efficacy and safety of colorectal ESD in Europe.

MATERIAL AND METHODS

A systematic search of PubMed for full-text studies including more than 20 cases of colorectal ESD emanating from European centres was performed. Data were independently extracted by two authors using predefined data fields, including efficacy and safety.

RESULTS

We included 15 studies containing a total of 1404 colorectal ESD cases (41% in the colon) performed between 2007 and 2018. Lesion size was 40 mm (range 24-59 mm) and procedure time was 102 min (range 48-176 min). En bloc resection rate was 83% (range 67-93%) and R0 resection rate was 70% (range 35-91%). Perforation rate was 7% (range 0-19%) and bleeding rate was 5% (range 0-12%). The percentage of ESD cases undergoing emergency surgery was 2% (range 0-6%). Additional elective surgery was performed in 3% of all cases due to histopathological findings showing deep submucosal invasion or more advanced cancer. The recurrence rate was 4% (range 0-12%) after a median follow-up time of 12 months (range 3-24 months).

CONCLUSIONS

This review shows that ESD is effective and safe for treating large and complex colorectal lesions in Europe although there is room for improvement. Thus, it is important to develop standardized and high-quality educational programs in colorectal ESD in Europe.

Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe

Background and study aims  Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods  Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results  Median size was 4 cm (range 1 - 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 - 588) and median proficiency was 7.2 cm ² /h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 - 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm ² /h) and the last study period (10.8 cm ² /h). Conclusions  This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.

Endoscopic submucosal dissection of malignant non-pedunculated colorectal lesions

BACKGROUND AND STUDY AIMS

 Endoscopic submucosal dissection (ESD) is an established method for en bloc resection of large non-pedunculated colorectal lesions in Asia but dissemination of ESD in Western countries is limited. The aim of this study was to evaluate the role of ESD in the management of malignant non-pedunculated colorectal lesions in a European center.

PATIENTS AND METHODS

Among 255 patients undergoing colorectal ESD between 2014 and 2016, 29 cases were identified as submucosal invasive cancers and included in this study. The main outcomes were en bloc, R0 and curative resection as well as procedural time, complications and recurrence.

RESULTS

Median tumor size was 40 mm (range 20 - 70 mm). Thirteen cancers were located in the colon and 16 were located in the rectum. Procedural time was 89 minutes (range 18 - 594 minutes). Complete resection was achieved in 28 cases, en bloc and R0 resection rates were 83 % and 69 %, respectively. Curative resection rate was 38 %. One case had a perforation in the sigmoid colon requiring emergency surgery. No significant bleeding occurred. Six patients underwent additional surgery after ESD, one of whom had residual tumor. One recurrence was detected in 20 patients that were followed-up endoscopically, median follow-up time was 13 months (range 2 - 30 months).

CONCLUSION

ESD seems to be a safe and effective method for treating non-pedunculated malignant colorectal lesions after careful patient selection and proper endoscopic training.

Using Endoscopic Submucosal Dissection as a Routine Component of the Standard Treatment Strategy for Large and Complex Colorectal Lesions in a Western Tertiary Referral Unit

BACKGROUND

Colorectal endoscopic submucosal dissection results in high rates of en bloc resection, few recurrences, and accurate diagnosis, and it is useful in lesions with significant fibrosis. However, endoscopic submucosal dissection has not been widely adopted by Western endoscopists and the published experience from Western centers is very limited.

OBJECTIVES

This study aims to report the outcomes from a UK tertiary center using colorectal endoscopic submucosal dissection as part of a standard lesion specific treatment approach.

DESIGN

This was a retrospective study.

SETTING

The study was conducted in a tertiary referral unit for interventional endoscopy in the United Kingdom.

PATIENTS

A total of 116 colorectal lesions were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection in 107 patients.

MAIN OUTCOME MEASURES

Outcomes included complications, recurrence, requirement for surgery, en bloc and R0 resection.

RESULTS

One hundred sixteen lesions (mean size 58.8mm) were resected using endoscopic submucosal dissection (n = 58) and hybrid endoscopic submucosal dissection (n = 58). Eighty-two (70.7%) had failed attempts at resection (n = 58) or extensive sampling before referral. Twelve contained invasive adenocarcinoma; endoscopic resection was curative in 6. Only 2 of 6 patients with noncurative endoscopic resection agreed to surgery, and none had lymph node metastases. Six of 7 perforations were successfully treated with endoscopic clips. Where endoscopic submucosal dissection was used alone, en bloc resection was achieved in 93% and R0 resection was achieved in 91%. Two patients experienced recurrence; both were managed with endoscopic resection.

LIMITATIONS

This was a retrospective study. Procedures were planned as endoscopic submucosal dissection, but some may have been converted to hybrid endoscopic submucosal dissection and not recorded.

CONCLUSION

Colorectal endoscopic submucosal dissection can be used in a Western center as part of a standard lesion-specific approach to deliver effective organ-conserving treatment to patients with large challenging lesions. Lesion assessment in Western practice should be improved to reduce the incidence of prior heavy manipulation and to guide appropriate referral. See Video Abstract at http://links.lww.com/DCR/A601.

Single-center implementation of endoscopic submucosal dissection (ESD) in the colorectum: Low recurrence rate after intention-to-treat ESD

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) shows higher R0 resection and lower local recurrence rates than endoscopic mucosal resection (EMR) in Japan. In Europe, independent learning of ESD in the colorectum is feasible, but yet to be analyzed for curative resection and recurrence rates.

METHODS

After experimental training under supervision by Japanese experts (T.O., N.Y.), three endoscopists independently carried out 83 ESD procedures intention-to-treat for lesions in the entire colorectum of 67 patients in a prospective registry (November 2009 to June 2016).

RESULTS

ESD was feasible in 80 (96%) colorectal neoplasias (mean diameter 33.6 [± 1.8] mm), and three more required conversion to piecemeal EMR. The lesions were adenomas in 66% with low-grade intraepithelial neoplasia (LGIN), 29% with high-grade intraepithelial neoplasia, and 5% with carcinomas (G2, pT1). ESD had to be facilitated by the final use of snaring (hybrid-ESD, n = 45), especially in the initial learning period. En-bloc resection rate was 85%. Complications were microperforations (7%, conducive to one hemicolectomy), and delayed bleeding (1%) without mortality or long-term morbidity. Residual adenomas with LGIN (5%) after hybrid-ESD did not recur after endoscopic ablation. All malignant neoplasias (34%) were curatively resected without recurrence after a mean follow up of 19.5 (± 3.2) months.

CONCLUSIONS

During independent ESD learning in the colorectum, ESD intention-to-treat showed a low recurrence rate after appropriate training, and hybrid-ESD showed acceptable complication and recurrence rates, justifying hybrid-ESD as a strategy for self-completion and rescue.

Colorectal endoscopic submucosal dissection (ESD) in the West - when can satisfactory results be obtained? A single-operator learning curve analysis

OBJECTIVES

Up to date we lack a detailed description of the colorectal endoscopic submucosal dissection (ESD) learning curve, that would represent the experience of the Western center. The aim of this study was to define the critical points of the learning curve and to draw up lesions qualification guidelines tailored to the endoscopists experience.

MATERIALS AND METHODS

We have carried out a single center prospective study. Between June 2013 and December 2016, 228 primary colorectal lesions were managed by ESD procedure. In order to create a learning curve model and to carry out the analysis the cases were divided into six periods, each consisting of 38 cases.

RESULTS

The overall en bloc resection rate was 79.39%. The lowest en bloc resection rate (52.36%) was observed in the first period. After completing 76 procedures, the resection rate surged to 86% and it was accompanied by the significant increase in the mean procedure speed of ≥9 cm²/h. Lesions localization and diameter had a signification impact on the outcomes. After 76 procedures, en bloc resection rate of 90.9 and 90.67% were achieved for the left side of colon and rectum, respectively. In the right side of colon statistically significant lower resection rate of 67.57% was observed.

CONCLUSION

We have proved that in the setting of the Western center, colorectal ESD can yield excellent results. It seems that the key to the success during the learning period is 'tailoring' lesions qualification guidelines to the experience of the endoscopist, as lesions diameter and localization highly influence the outcomes.

Colorectal endoscopic submucosal dissection (ESD)

Endoscopic submucosal dissection (ESD) is an interventional procedure for en-bloc resection of gastrointestinal lesions. ESD is a challenging and can involve a reasonable degree of risk, therefore case selection is of crucial importance, especially in the colo-rectum. This procedure should be mainly used for dissection of lesions when there is a high suspicion of superficial malignant invasion; several classifications have been proposed in order to better identify lesions suitable for ESD. However, case selection is still an issue, since only about 8-10% of dissected lesions are superficially invading cancer and most of cases involve benign or massively invading cancer. In addition, significant differences have been reported between Asian and Western countries in regard to main outcomes, and therefore measures should be adopted as soon as possible to reduce this discrepancy.

Efficacy, Safety, and Overall Quality of Life of Endoscopic Submucosal Dissection for Early Colorectal Cancer in Elderly Patients

Purpose

Studies reporting the treatment of early colorectal cancer (ECC) by endoscopic submucosal dissection (ESD) in elderly patients are lacking in China. The aim was to evaluate the efficacy, safety and overall quality of life of elderly patients with ECC who undergoing ESD.

Methods

Three hundred and seventy-nine patients with 401 colorectal lesions entered into our study from March 2013 to March 2016 (Patients with an age 70 years old or older were divided into the elderly group and those who were less than 70-year-old entered the non-elderly group).

Results

No significant differences were found in sex ratio, body mass index, location, endoscopic classification, pathological pattern, lesion size, mean procedure time, hospitalization days, complete excision, and en bloc resection rate between the two groups (P > 0.05). No significant differences were observed between the groups in terms of complications during and after ESD procedure (P > 0.05). There were no statistical differences between two groups in Quality of life index (QL-Index) and European Organization for Research and Treatment quality of life version 3.0 questionnaire (EORTC QLQ-C30) scores (P > 0.05).

Conclusion

ESD was relatively safe and effective for elderly patients with ECC, and it may be an recommended first-line treatment.

Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis

Background and study aims: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows en-bloc resection of gastrointestinal tumor. We systematically review the medical literature in order to evaluate the safety and efficacy of colorectal ESD. Patients and methods: We performed a comprehensive literature search of MEDLINE, EMBASE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of colorectal ESD. Results: Included in this study were 13833 tumors in 13603 patients (42 % female) who underwent colorectal ESD between 1998 and 2014. The R0 resection rate was 83 % (95 % CI, 80 - 86 %) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in continent (P = 0.004), study design (P = 0.04), duration of the procedure (P = 0.009), and, marginally, by average tumor size (P = 0.09). Endoscopic en bloc and curative resection rates were 92 % (95 % CI, 90 - 94 %) and 86 % (95 % CI, 80 - 90 %), respectively. The rates of immediate and delayed perforation were 4.2 % (95 % CI, 3.5 - 5.0 %) and 0.22 % (95 % CI, 0.11 - 0.46 %), respectively, while rates of immediate and delayed major bleeding were 0.75 % (95 % CI, 0.31 - 1.8 %) and 2.1 % (95 % CI, 1.6 - 2.6 %). After an average postoperative follow up of 19 months, the rate of tumor recurrence was 0.04 % (95 % CI, 0.01 - 0.31) among those with R0 resection and 3.6 % (95 % CI, 1.4 - 8.8 %) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 1.0 % (95 % CI, 0.42 - 2.1 %). Conclusions: Our meta-analysis, the largest and most comprehensive assessment of colorectal ESD to date, showed that colorectal ESD is safe and effective for colorectal tumors and warrants consideration as first-line therapy when an expert operator is available.

[Endoscopic surgery]

Endoscopic surgery of the stomach/gastrointestinal tract was developed in the 1990s in Japan as a minimally invasive method of removing early-stage tumours, using a gastro-/coloscope instead of open or laparoscopic surgery. Its advantages are obvious, in that the patient is spared more major surgery, the hospital saves on resources as well as admission to a ward, and society is spared the costs of days of sickness absence. Endoscopic submucosal dissection is considered the most difficult technique, but it allows for the accurate dissection of large tumours. In 1999, Japanese surgeon Takuji Gotoda and his team were the first to perform these types of dissections of early cancers in the rectum using a diathermic needle and a flexible scope.

Colorectal endoscopic submucosal dissection from a Western perspective: Today’s promises and future challenges

Over the last few years, endoscopic submucosal dissection (ESD) has shown to be effective in the management of early colorectal neoplasms, particularly in Asian countries where the technique was born. In the Western world, its implementation has been slow and laborious. In this paper, the indications for ESD, its learning model, the available methods to predict the presence of deep submucosal invasion before the procedure and the published outcomes from Asia and Europe will be reviewed. Since ESD has several limitations in terms of learning achievement in the West, and completion of the procedure for the first cases is difficult in our part of the world, a short review on colorectal assisted ESD has been included. Finally, other endoscopic and surgical treatment modalities that are in competition with colorectal ESD will be summarized.

How to establish endoscopic submucosal dissection in Western countries

Endoscopic submucosal dissection (ESD) has been invented in Japan to provide resection for cure of early cancer in the gastrointestinal tract. Professional level of ESD requires excellent staging of early neoplasias with image enhanced endoscopy (IEE) to make correct indications for ESD, and high skills in endoscopic electrosurgical dissection. In Japan, endodiagnostic and endosurgical excellence spread through personal tutoring of skilled endoscopists by the inventors and experts in IEE and ESD. To translocate this expertise to other continents must overcome two fundamental obstacles: (1) inadequate expectations as to the complexity of IEE and ESD; and (2) lack of suitable lesions and master-mentors for ESD trainees. Leading endoscopic mucosal resection-proficient endoscopists must pioneer themselves through the long learning curve to proficient ESD experts. Major referral centers for ESD must arise in Western countries on comparable professional level as in Japan. In the second stage, the upcoming Western experts must commit themselves to teach skilled endoscopists from other referral centers, in order to spread ESD in Western countries. Respect for patients with early gastrointestinal cancer asks for best efforts to learn endoscopic categorization of early neoplasias and skills for ESD based on sustained cooperation with the masters in Japan. The strategy is discussed here.

Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis

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.

Safe and efficient colorectal endoscopic submucosal dissection in European settings: is successful implementation of the procedure possible?

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is gaining worldwide recognition as valuable alternative to treat early colorectal neoplasia. Although the method is perceived as technically difficult and carries a higher risk of complications than conventional endoscopy, the oncological results are very promising. Herein we aim to present the treatment outcomes of ESD for lesions in the colon and rectum at the beginning of our learning curve.

METHODS

Seventy consecutive cases of colorectal ESD carried out in our center between June 2013 and May 2014 were analyzed. Effectiveness of dissection, complications and tumor recurrence after 3 months of treatment were investigated.

RESULTS

Of the 70 ESD procedures, 39 were in the rectum, 10 in the sigmoid, eight in the descending colon, six in the ascending colon and seven in the cecum. Average size of removed tumors was 38.1 mm. In 50 cases, en-block resection was achieved. In this group, 97% cases were R0 resection. Perforation occurred in four cases (5.7%) of which three were managed with endoclips. In four cases, significant bleeding occurred. In a follow-up examination, two of 41 patients (4.9%) had recurrent adenoma that was successfully endoscopically removed.

CONCLUSIONS

The results confirm that ESD is an effective and safe modality for treatment of colorectal epithelial neoplasia in the colon and rectum even at the beginning of the learning curve. After proper training, results in Europe and Japan may be comparable.

Factors predicting clinical outcomes of endoscopic submucosal dissection in the rectum and sigmoid colon during the learning curve

BACKGROUND AND STUDY AIMS

Colorectal endoscopic submucosal dissection (ESD) is associated with significant technical difficulty, long procedure time, and increased risk of complications, especially perforation. This study aimed to determine the factors associated with clinical results of ESD during the learning curve.

PATIENTS AND METHODS

In total, 44 patients with sessile and flat rectal and sigmoid colon lesions underwent ESD from November 2009 to September 2013. The procedure time, resection method, tumor size, location, gross morphology, presence of fibrosis, histologic findings, rates of en bloc and piecemeal resections and perforation were analyzed. The ESD procedure was classified as technically difficult in the case of procedure time > 120 minutes and/or piecemeal resection. The whole study time was divided into two periods: first period: resections 1 - 22, second period: resections 23 - 44.

RESULTS

En bloc and R0 resection have been achieved in 84.1 % of lesions. The mean procedure time was 119.95 ± 11.22 minutes (range 25 - 360 minutes). Perforation was seen in five cases (11.4 %). A larger tumor size was a risk factor for difficult ESD (P = 0.0001). A finding of fibrosis was a risk factor for piecemeal ESD (P = 0.0074), and perforation (P = 0.0012). There was a high direct positive correlation between tumor size and operation time (r = 0.83, P < 0.0001, 0.95 and 0.99 confidence interval for rho 0.71 - 0.904). There was no significant difference between the first and second period in terms of mean procedure time, en bloc resection or complication rate.

CONCLUSION

A larger tumor size was associated with technically difficult ESD. Severe submucosal fibrosis was a risk factor for both piecemeal resection and perforation.

Endoscopic Submucosal Dissection (ESD) in Colorectal Tumors

Background

Endoscopic submucosal dissection (ESD) – initially developed for the treatment of early gastric cancer in Japan – is an attractive option for en bloc resection of larger sessile or flat colorectal neoplasia.

Methods

A review of the current literature on colorectal ESD was carried out.

Results

In contrast to conventional endoscopic mucosal resection (EMR), ESD for larger colorectal neoplasia yields high en bloc resection rates and very low recurrence rates. The frequency of delayed bleeding is similar for EMR and ESD. Higher perforation rates during ESD are mostly due to microperforations identified and treated during the intervention, and are therefore of minor clinical relevance. A major disadvantage of ESD is the necessity for high-level endoscopic skills and long procedure times. ESD also has the potential to replace laparoscopic surgery or transanal endoscopic microsurgery mainly due to its lower complication rates.

Conclusion

ESD for the resection of larger flat or sessile colorectal lesions has potential advantages over conventional EMR or minimally invasive surgery. Due to the low incidence of early gastric cancer, experience with ESD will remain limited in Western countries. The spread of colorectal ESD will depend on adequate training opportunities and also on modifications yielding a reduction in procedure time.

Clinical practice of endoscopic submucosal dissection for early colorectal neoplasms by a colonoscopist with limited gastric experience

Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.