Achieving R0 resection in the colorectum using endoscopic submucosal dissection (original) (raw)
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CURRENT STATUS AND FUTURE PERSPECTIVES OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL TUMORS
Digestive Endoscopy, 2012
Endoscopic submucosal dissection (ESD) allows for en bloc tumor resection irrespective of the size of the lesion. In Japan, ESD has been established as a standard method for endoscopic ablation of malignant tumors in the upper gastrointestinal tract.Although the use of colorectal ESD has been gradually spreading with the development of numerous devices, ESD has not yet been fully established as a standard therapeutic method for colorectal lesions. Currently, colorectal ESD is performed as an 'advanced medical treatment' without national health insurance coverage. With the recent accumulation of numerous cases, the safety and simplicity of colorectal ESD have improved remarkably. Currently in Japan, a prospective multicenter cohort study organized by the Japan Gastroenterological Endoscopy Society is ongoing to clarify the safety and efficacy of colorectal ESD to obtain remuneration from national health insurance. In this report, we showed the outcome regarding safety and efficacy of colorectal ESD through a review of the published work. Of 2719 cases with colorectal ESD at 13 institutions, the complete en bloc resection and perforation rates were 82.8% (61-98.2%, 2082/2516) and 4.7% (1.4-8.2%, 127/2719), respectively. Additional surgery for perforation was very rare because perforations were tiny enough to be closed endoscopically by clips in most of the cases and treated conservatively. In the near future, colorectal ESD will be a common therapeutic method for early colorectal carcinoma.
Clinical Gastroenterology and Hepatology, 2007
Background & Aims: The clinical outcomes for endoscopic submucosal dissection (ESD), a novel endoluminal surgery for gastrointestinal neoplasm in the colorectum, are reported. Methods: ESD was performed on 186 consecutive patients with 200 colorectal epithelial neoplasms who had preoperative diagnoses of mucosal or slight submucosally invasive neoplasms. In addition, these could be of large size, with submucosal fibrosis, or located on an intestinal fold. The therapeutic efficacy and safety were assessed. Results: The targeted lesions consisted of 102 adenomas, 72 noninvasive carcinomas, and 26 invasive carcinomas. Seven lesions (3.5%) were histologically considered to be at substantial risk for nodal metastasis after ESD. The rate of en bloc resection was 91.5% (183/200), and en bloc resection with tumor-free lateral/basal margins (R0 resection) was 70.5% (141/200). Two lesions (1%) required emergency colonoscopies as a result of hematochezia after ESD. Eleven (5.5%) immediate perforations that occurred during ESD were successfully managed conservatively, but 1 (0.5%) delayed perforation required laparotomy. Two multiple-piece resections of 111 tumors (1.8%), which were successfully followed by colonoscopy (median follow-up, 18 months; range, 12-60 months), were found as locally recurrent tumors 2 and 21 months after ESD. No lymph node or distant metastasis was detected in 77 patients with noninvasive or invasive carcinoma (median follow-up, 24 months; range, 6-74 months). Conclusions: ESD is applicable in the colorectum with promising results. However, when considering the risks and benefits, piecemeal endoscopic resection or colorectal resection might be more appropriate for some subgroups of large flat neoplasms or those with submucosal fibrosis.
Digestive Endoscopy, 2009
Early stage colorectal tumors can be removed by endoscopic mucosal resection (EMR) but larger tumors (> or =20 mm) may require piecemeal resection. The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of lesions regardless of size and shape. However ESD of colorectal tumor is technically difficult. As the resources, we perform EMR with small incision (EMR with SI) for more reliable EMR, and also ESD with snaring (simplified ESD) for easier and safer ESD. AIM & METHODS: The aim of the study was to retrospectively compare the treatment results of the following 3 methods (EMR with SI/ simplified ESD/ ESD). We treated 24/44/468 colorectal tumors, and examined the tumor size, resected specimen size, procedure time, en-bloc resection rate, complication rate. The median tumor size (mm) (EMR with SI/simplified EMR/ESD) was 20/17/30 (EMR with SI vs simplified ESD: P = n.s, simplified ESD vs ESD: P < 0.0001). The median resected specimen size (mm) was 22.5/26/41 (EMR with SI vs simplified ESD: P = 0.0018, simplified ESD vs ESD: P < 0.0001). The procedure time (min.) was 19/27/60 (EMR with SI vs simplified ESD: P = n.s, simplified ESD vs ESD: P < 0.0001) The en-bloc resection rate (%) was 83.3/90.9/98.9. The complication rate (post-operative bleeding rate/perforation rate) was 0/0, 2.3/4.5, 1.5/1.5 (simplified ESD vs ESD: P = n.s). Endoscopic mucosal resection with small incision (EMR with SI) and ESD with snaring (simplified ESD) are a good option to fill the differences between conventional EMR and ESD, and also considered to become nice steps to the introduction of ESD.
Two-step ESD: an option for en-bloc resection of extensive colorectal laterally spreading tumors
Endoscopy International Open, 2019
Endoscopic mucosal resection (EMR) is a well-established treatment for colorectal laterally spreading tumor (LTS) [1]. However, for lesions over 20 mm, the probability of piecemeal resection and local recurrence are higher [2]. Endoscopic submucosal dissection (ESD), initially developed for treatment of gastric neoplasms, made possible complete en-bloc resection of colorectal LST larger than 20 mm [3]. Currently, ESD is feasible and safely performed in Asian countries and in some western centers [4]. For extensive lesions, ie, those measuring over 10 cm, ESD is associated with technical difficulty, longer procedural time, and higher risk of adverse events [5]. There are only a few case reports of en-bloc resection with ESD of extensive LSTs. Even for experts, under ideal circumstances and with adequate accessories, performing the procedure in these cases remains a challenge [5]. Therefore, the aim of this study was to describe an alternative that enables en-bloc ESD of extensive LSTs: two-step ESD.
Gastrointestinal Endoscopy, 2022
Background and Aims: Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the removal of large lesions in the GI tract. Because of the complexity of the technique, implementation in Western health care has been slow. An ESD procedure is usually followed by hospital admission. Our aim was to investigate if ESD of colorectal lesions can be performed in an outpatient setting. Methods: Six hundred sixty colorectal ESD procedures between 2014 and 2020 were evaluated retrospectively. All patients referred to the unit with an early colorectal neoplasm >20 mm without signs of deep invasion were considered eligible for an ESD procedure. Results: Of 660 lesions, 323 (48.9%) were localized in the proximal colon, 102 (15.5%) in the distal colon, and 235 (35.6%) in the rectum. Median lesion size was 38 mm (interquartile range, 30-50) and median procedure duration 70 minutes (interquartile range, 45-115). En-bloc resection was achieved in 620 cases (93.9%). R0 resection was achieved in 492 en-bloc resections (79.4%), whereas the number of Rx and R1 resections was 124 (20.0%) and 4 (.6%), respectively. Low-grade dysplasia was found in 473 cases (71.7%), high-grade dysplasia in 144 (21.8%), and adenocarcinoma in 34 (5.1%). Six hundred twelve procedures (92.7%) were scheduled as outpatient, and 33 of these underwent unplanned admission. Forty-eight cases (7.3%) were planned as inpatient procedures. The rate of full wall perforation was 38 (5.8%), in which 35 (92.1%) were managed endoscopically and 3 patients (7.9%) required emergency surgery. Forty-six patients (7.0%) sought medical attention within 30 days because of bleeding (21 [3.2%]), abdominal tenderness (16 [2.4%]), and other reasons (9 [1.4%]). Twenty-four of these patients were admitted for observation for a median of 2 days (range, 1-7). Ten of these patients were treated with antibiotics, and 6 patients required blood transfusion. None required additional surgery. Conclusions: ESD of colorectal lesions can be safely performed in an outpatient setting in a well-selected patient. (Gastrointest Endosc 2022;96:101-7.) Colorectal cancer is the fourth most common cause of cancer-related death in Sweden. 1 The pathogenesis is described by the adenoma-carcinoma pathway, 2 and colorectal screening programs, implemented around the world, lower the incidence of colorectal cancer and colon cancer-associated mortality. 3,4 Endoscopic submucosal dissection (ESD) was developed to manage larger flat adenomas (>20 mm) and early adenocarcinomas where snare polypectomy and EMR failed to achieve en-bloc resection. ESD can be used for large (>10 cm) and circumferential lesions. It gives the pathologist an en-bloc resection specimen where important features such as invasion depth, lymphovascular invasion, tumor budding, and R0 resection can be assessed and provides the clinician with reliable information for considering future treatment strategies. 5 When ESD and EMR are compared, Abbreviation: ESD, endoscopic submucosal dissection.
United European gastroenterology journal, 2016
Background and aims: This systematic review and meta-analysis compares the safety and effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of flat and sessile colorectal lesions >20 mm preoperatively assessed as noninvasive. Methods: We reviewed the literature published between January 2000 and March 2014. Pooled estimates of the proportion of patients with en bloc, R0 resection, complications, recurrence, and need for further treatment were compared in a metaanalysis using fixed and random effects. Results: A total of 11 studies and 4678 patients were included. The en bloc resection rate was 89.9% for ESD vs 34.9% for EMR patients (RR 1.93 p < 0.001). The R0 resection rate was 79.6% for ESD vs 36.2% for EMR patients (RR 2.01 p < 0.001). The rate of perforation was 4.9% for the ESD group and 0.9% for EMR (RR 3.19, p < 0.001), while the rate of bleeding was 1.9% for ESD and 2.9% for EMR (RR 0.68, p ΒΌ 0.070). Therefore, the overall need for further surgery, including surgery for oncologic reasons and surgery for complications, was 7.8% for ESD and 3.0% for EMR (RR 2.40, p < 0.001). Conclusions: ESD achieves a higher rate of en bloc and R0 resection compared to EMR, at the cost of a higher risk of complications. This, added to an increased need for surgery for oncologic reasons for a plausible tendency to extend indication for endoscopic excision, increases the risk of further surgery after ESD.