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Journal of Digestive Diseases 2015; 16; 14–21
doi: 10.1111/1751-2980.12207
Original article
Efficacy of endoscopic submucosal dissection for residual or recurrent superficial colorectal tumors after endoscopic mucosal resection Gabriel RAHMI,* Shinwa TANAKA,† Yoshiko OHARA,† Tsukasa ISHIDA,† Tetsuya YOSHIZAKI,† Yoshinori MORITA,† Takashi TOYONAGA† & Takeshi AZUMA† *Department of Hepatogastroenterology and Digestive Endoscopy, Université Paris Descartes, Georges Pompidou European Hospital, Paris, France; and †Department of Hepatogastroenterology and Digestive Endoscopy, Kobe University Hospital, Kobe, Japan
OBJECTIVE: Superficial colorectal tumors can be treated effectively by endoscopic submucosal dissection (ESD). Few data are available on using ESD for residual or recurrent tumors after the first endoscopic resection. This study aimed to evaluate the efficacy of ESD for these lesions. METHODS: In all, 28 patients with residual or recurrent superficial colorectal tumors were referred to the Kobe University Hospital for ESD. The therapeutic outcomes and the possible factors predictive of procedure difficulties for ESD were analyzed. RESULTS: In total, 27 (96.4%) patients were successfully treated using ESD. There was no related KEY WORDS: treatment.
CONCLUSIONS: The use of ESD allowed a high rate of en bloc resection for residual or locally recurrent colorectal tumors. Furthermore, these lesions should be treated by ESD as a first-line treatment.
colorectal neoplasms, complications, endoscopic submucosal dissection, residual tumor,
Correspondence to: Gabriel RAHMI, Department of Hepatogastroenterology and Endoscopy, Georges Pompidou European Hospital, 20 rue Leblanc, 75015, Paris, France. Email: [email protected] Conflict of interest: Dr TOYONAGA invented the Flush knife in conjunction with Fujifilm (Tokyo, Japan), and receives royalties from its sale. None for Drs RAHMI, TANAKA, OHARA, ISHIDA, YOSHIZAKI, MORITA and AZUMA. © 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
14
immediate complication. One patient had a delayed perforation which was then treated surgically. En bloc R0 resection was possible in all the patients and curative resection in 26 patients (92.9%). One invasive cancer was treated surgically. More than one previous endoscopic resection was the only significant predictive factor for the difficulty in performing ESD. None of the patients experienced recurrence during a follow-up of 22 months (range 3–41 months).
INTRODUCTION Superficial colorectal neoplasms are associated with a low risk for lymph node involvements and predict a good prognosis for such patients. Endoscopic resection is a curative therapy with low morbidity and mortality and a low cost-effectiveness ratio. Therefore, endoscopic mucosal resection (EMR) is conventionally used to remove superficial colorectal neoplasms in clinical setting, particularly in Western countries.1–3 However, the risk in piecemeal resection associated
Journal of Digestive Diseases 2015; 16; 14–21 with resection margins is not determinable by histology, and it is high for lesions larger than 20 mm in diameter.4 Residual lesion or local tumor recurrence may occur after EMR in approximately 6–27% of all patients,4–7 and a second resection could be technically difficult due to severe fibrosis. With the development of endoscopic techniques and specialized devices, endoscopic submucosal dissection (ESD), a more recent technique that provides a high en bloc resection rate, has gradually emerged as a feasible therapy for colorectal lesions.8–13 Even if ESD is also more difficult in treating residual or locally recurrent lesions, it may allow for complete en bloc secondary resection, which has the advantage of avoiding surgery and frequent followup examinations. The aim of our study was to evaluate the efficacy of ESD for the treatment of residual or locally recurrent colorectal lesions after a primary endoscopic resection. The secondary objective was to assess the potential time-consuming predictive factors reflecting the difficulty of the procedure. PATIENTS AND METHODS Study population From December 2008 to July 2013, 629 consecutive patients with colorectal tumor were referred to the Department of Hepatogastroenterology and Digestive Endoscopy of Kobe University Hospital (Kobe, Japan) for ESD. After being provided with information about the technique, all the patients gave their informed consent before their enrollment. This study was approved by the Institutional Review Board. Inclusion and exclusion criteria for ESD Inclusion criteria were: (i) residual or locally recurrent lesions defined as persistent lesions at the same colorectal site after incomplete or complete endoscopic resection (the difference between a residual or a locally recurrent lesion could not be established because of their similar endoscopic aspect); (ii) previous pathological examination showing superficial colorectal tumor, including adenoma, intramucosal carcinoma, or those with submucosal invasion of less than 1000 μm in depth; and (iii) a lesion without invasion upon macroscopic endoscopic evaluation using the Paris morphological14 and Kudo classifications15.
Endoscopic resection for colon tumor
15
Exclusion criteria were: (i) colorectal carcinoma with submucosal invasion of deeper than 1000 μm upon previous histological examination; and (ii) a positive invasive pattern upon macroscopic endoscopic evaluation. Technique for colorectal ESD All patients were admitted the day before ESD for bowel preparation with 2 L polyethylene glycol electrolyte solution. Conscious sedation was performed intravenously using a combination of hydroxyzine and pethidine in all cases. Carbon dioxide insufflation was systematically used. Four endoscopists, who had performed more than 100 ESD, performed the procedures. Instruments for colorectal ESD
Endoscopic system and electrosurgical generator A single-channel endoscope (CF-240I; Olympus, Tokyo, Japan) was used. A 4-mm-long transparent hood was systematically attached to the tip of the endoscope (D-201-13404; Olympus) to facilitate optimal field visualization and stable dissection. A small–caliber-tip transparent hood (ST hood) (DH-16CR; Fujinon Optical, Tokyo, Japan) was used, a narrow-tip hood used to facilitate the entry of endoscopic devices into the submucosal layer, particularly in cases with severe fibrosis. A VIO 300 D (Erbe Elektromedizin, Tübingen, Germany) electrosurgical generator was used during the ESD procedures.
Devices used during ESD Flush knife (DK-2618JN; Fujinon Optical) was used for all patients.16 This is a short needle knife with special characteristics that comes in a diameter of 0.5 mm and needle lengths of 1.0, 1.5 or 2.0 mm. This knife allows for greater flexibility in the angle of insertion than the conventional needle knife and can dissect severe fibrosis. In patients with severe submucosal fibrosis, the knife with a length of 1.0 mm was preferentially used. This standard Flush knife was used at the beginning of the study, and ESD was then performed using a ball-tipped needle knife (Flush knife-BT), which is equipped with a spherical tip 0.9 mm in diameter and lengths ranging between 1.5 and 2.0. This more recently designed Flush knife-BT was developed to improve the hemostatic capabilities
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
16
G Rahmi et al.
of the standard Flush knife.17 Saline solution was flushed down the device sheath alongside the needle to enable improved submucosal lifting using a flushing pump (FTS JW-2; Fujinon) without the need for additional injection; however, the flushing does not cut or dissect the submucosal layer because the pressure is relatively low (0.3 MPa).
Journal of Digestive Diseases 2015; 16; 14–21
Marking Marking of the colorectal tumors was not usually necessary because the limit between the lesions and normal mucosa was quite clear after spraying the mucosa with indigo carmine.
Local injection Colorectal ESD technique The ESD procedure for colorectal tumors is shown in Fig. 1.
Sodium hyaluronate was initially injected into the submucosal layer in all cases to lift the lesion, allowing for good surveillance of the lesion. During the procedure, saline solution was injected from the Flush knife. Some cases with severe fibrosis required additional sodium hyaluronate injection via a standard injection needle.
Mucosal incision Mucosal incision was performed approximately 5 mm outside the edges of the tumors. The Flush knife at 1.5 mm was used for the mucosal incision, starting at the anal side. An additional incision was performed from the anal side to the oral side to create a circumferential incision.
Submucosal dissection The Flush knife was used at 1.5 mm except in cases of severe fibrosis (1.0 mm) and when a parallel approach to the muscle layer was difficult. An additional dissection was performed after appropriate local injection. Management of eventual complications
Hemostasis and vessel coagulation
Figure 1. Endoscopic submucosal dissection (ESD) for colorectal tumors. (a) Residual lesion in the sigmoid colon. This lesion has received endoscopic mucosal resection four times previously. (b) Lateral spreading tumor nodular mixed type lesion 43 mm in size. (c) Severe fibrosis is found at the center of the lesion. (d) The area with severe fibrosis can be dissected with a 1.0-mm Flush knife needle. (e) Ulcer bed after resection. (f) Pathological diagnosis of mucosal cancer with severe fibrosis.
Meticulous hemostasis was applied during the procedure. Diffuse bleeding (or oozing) was generally treated with the tip of the knife with forced coagulation. Pulsating bleeding points and thick vessels were grasped and retracted with a hemostatic forceps (Coagrasper, FD-411QR; Olympus) with soft coagulation. At the end of the procedure, each vessel visible in the base of the mucosal defect after the procedure was coagulated.
Perforation Immediate perforation was recognized during the procedure and treated by endoscopic clipping. Patients were also fasted and received antibiotics. Abdominal
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Journal of Digestive Diseases 2015; 16; 14–21 computed tomography (CT) was performed after ESD, and clinical examinations were completed every day during hospitalization. Delayed perforations were treated surgically. Histopathological assessment The resected specimens were collected intact, stretched and pinned out, fixed in formalin, cut into 2-mm sections and assessed microscopically. En bloc resection was defined as a tumor removed in a single piece. That resected as a single piece in the absence of lateral or deep margin invasions was regarded as en bloc R0 resection. En bloc R0 curative resection was defined as follows: (i) adenoma; (ii) intramucosal well-differentiated carcinoma; and (iii) minimally invasive submucosal well-differentiated carcinoma (submucosal invasion less than 1000 μm in depth) without lymphovascular invasion. Endoscopic follow-up The curatively resected cases were followed up with endoscopic examinations one year after ESD. Biopsy samples were taken if a recurrent tumor was visible upon chromoscopy. Statistical analysis Statistical analyses were performed using SPSS 18.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation (SD) or medians and ranges and categorical parameters were expressed as numbers and frequencies. The efficacy of ESD was evaluated via the en bloc R0 curative rate. Factors potentially affecting the operating time and reflecting the difficulty of the procedure (operating time ≥90 min) were: tumor size, lesion location (left colon, right colon or rectum), macroscopic type (granular lateral spreading tumor or non-granular lateral spreading tumor), previous resection (number of EMR before ESD), and depth of invasion upon histological examination. Fisher’s exact test was used for descriptive analysis. P ≤ 0.05 were considered statistically significant. RESULTS Characteristics of the patients and lesions Altogether 28 patients were found to have locally recurrent or residual colorectal lesions, including 15
Endoscopic resection for colon tumor
17
men. The mean age of the patients was 66.5 ± 9.0 years. ESD was performed in 27 of the 28 patients. ESD was technically impossible for the remaining patient with severe fibrosis who was referred to a surgeon. The clinicopathological features of the patients and the tumors are detailed in Table 1. The lesions were essentially localized at the distal colon and rectum, with a mean tumor size of 38 mm (range 10–180 mm). The mean procedure time was 63 min (range 22–248 min). Tumors showed non-lifting signs because of submucosal fibrosis in all the patients. A standard Flush knife was used at the beginning of the procedure, and a Flush knife-BT was used for most patients. For six patients, two needles with different lengths were used during the procedure. Endoscopic characteristics during ESD are shown in Table 2. Patients’ outcomes and histopathology of the lesions Complete en bloc resection was achieved in 96.4% (27/28) of the patients (Fig. 2). At the end of the procedure, macroscopic complete resection was achieved in all the patients. After histological examination, en bloc R0 curative resection rate was confirmed to be 92.9% (26/28). One 60-year-old male patient who was treated for a 40-mm lesion at the transverse colon had an invasive cancer with deep infiltration in the submucosa (>3000 μm in depth). This patient was referred for surgical treatment. Histological examination showed curative resection in the other 26 cases (one carcinoid tumor, eight adenomas with dysplasia and 17 well-differentiated carcinomas without lymphovascular involvements). Table 1. Characteristics of patients treated for residual or locally recurrent colorectal lesions (n = 28) Male, n (%) Age, years (mean ± SD) Time between previous resection and ESD, months (median [range]) Location of tumors, n Caecum/ascendant colon/transverse colon Descendant colon/sigmoid/rectum Macroscopic tumor aspect, n 0–I pedunculated/sessile 0–IIa/0–IIb/0–IIc Lateral spreading tumor Granular/non-granular Submucosal tumor
15 (53.6) 66.5 ± 9.0 24 (4–41)
2/2/7 2/8/7 0/3 8/0/1 7/8 1
ESD, endoscopic submucosal dissection; SD, standard deviation.
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
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G Rahmi et al.
Journal of Digestive Diseases 2015; 16; 14–21
Table 2. Endoscopic characteristics during endoscopic submucosal dissection in patients treated for residual or locally recurrent colorectal lesions (n = 28) Flush knife (mm), n Ball-tipped: 2/1.5 Needle tip: 2/1.5/1 Ancillary device, n ST hood Resection type, n En bloc Failure Piecemeal Operating time, min (median [range]) Size of tumor, mm (median [range]) Size of specimen, mm (median [range]) Bleeding, n Perforation, n Immediate Delayed Length of hospital stay, days (median [range])
12/10 0/5/6 3 27 1 0 63 (22–248) 17.5 (4–68) 38 (10–180) 0 0 1 7 (6–24)
Table 3. Factors potentially affecting the operating time and reflecting the difficulty of the procedure Operating time n (%)
Journal of Digestive Diseases 2015; 16; 14–21
doi: 10.1111/1751-2980.12207
Original article
Efficacy of endoscopic submucosal dissection for residual or recurrent superficial colorectal tumors after endoscopic mucosal resection Gabriel RAHMI,* Shinwa TANAKA,† Yoshiko OHARA,† Tsukasa ISHIDA,† Tetsuya YOSHIZAKI,† Yoshinori MORITA,† Takashi TOYONAGA† & Takeshi AZUMA† *Department of Hepatogastroenterology and Digestive Endoscopy, Université Paris Descartes, Georges Pompidou European Hospital, Paris, France; and †Department of Hepatogastroenterology and Digestive Endoscopy, Kobe University Hospital, Kobe, Japan
OBJECTIVE: Superficial colorectal tumors can be treated effectively by endoscopic submucosal dissection (ESD). Few data are available on using ESD for residual or recurrent tumors after the first endoscopic resection. This study aimed to evaluate the efficacy of ESD for these lesions. METHODS: In all, 28 patients with residual or recurrent superficial colorectal tumors were referred to the Kobe University Hospital for ESD. The therapeutic outcomes and the possible factors predictive of procedure difficulties for ESD were analyzed. RESULTS: In total, 27 (96.4%) patients were successfully treated using ESD. There was no related KEY WORDS: treatment.
CONCLUSIONS: The use of ESD allowed a high rate of en bloc resection for residual or locally recurrent colorectal tumors. Furthermore, these lesions should be treated by ESD as a first-line treatment.
colorectal neoplasms, complications, endoscopic submucosal dissection, residual tumor,
Correspondence to: Gabriel RAHMI, Department of Hepatogastroenterology and Endoscopy, Georges Pompidou European Hospital, 20 rue Leblanc, 75015, Paris, France. Email: [email protected] Conflict of interest: Dr TOYONAGA invented the Flush knife in conjunction with Fujifilm (Tokyo, Japan), and receives royalties from its sale. None for Drs RAHMI, TANAKA, OHARA, ISHIDA, YOSHIZAKI, MORITA and AZUMA. © 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
14
immediate complication. One patient had a delayed perforation which was then treated surgically. En bloc R0 resection was possible in all the patients and curative resection in 26 patients (92.9%). One invasive cancer was treated surgically. More than one previous endoscopic resection was the only significant predictive factor for the difficulty in performing ESD. None of the patients experienced recurrence during a follow-up of 22 months (range 3–41 months).
INTRODUCTION Superficial colorectal neoplasms are associated with a low risk for lymph node involvements and predict a good prognosis for such patients. Endoscopic resection is a curative therapy with low morbidity and mortality and a low cost-effectiveness ratio. Therefore, endoscopic mucosal resection (EMR) is conventionally used to remove superficial colorectal neoplasms in clinical setting, particularly in Western countries.1–3 However, the risk in piecemeal resection associated
Journal of Digestive Diseases 2015; 16; 14–21 with resection margins is not determinable by histology, and it is high for lesions larger than 20 mm in diameter.4 Residual lesion or local tumor recurrence may occur after EMR in approximately 6–27% of all patients,4–7 and a second resection could be technically difficult due to severe fibrosis. With the development of endoscopic techniques and specialized devices, endoscopic submucosal dissection (ESD), a more recent technique that provides a high en bloc resection rate, has gradually emerged as a feasible therapy for colorectal lesions.8–13 Even if ESD is also more difficult in treating residual or locally recurrent lesions, it may allow for complete en bloc secondary resection, which has the advantage of avoiding surgery and frequent followup examinations. The aim of our study was to evaluate the efficacy of ESD for the treatment of residual or locally recurrent colorectal lesions after a primary endoscopic resection. The secondary objective was to assess the potential time-consuming predictive factors reflecting the difficulty of the procedure. PATIENTS AND METHODS Study population From December 2008 to July 2013, 629 consecutive patients with colorectal tumor were referred to the Department of Hepatogastroenterology and Digestive Endoscopy of Kobe University Hospital (Kobe, Japan) for ESD. After being provided with information about the technique, all the patients gave their informed consent before their enrollment. This study was approved by the Institutional Review Board. Inclusion and exclusion criteria for ESD Inclusion criteria were: (i) residual or locally recurrent lesions defined as persistent lesions at the same colorectal site after incomplete or complete endoscopic resection (the difference between a residual or a locally recurrent lesion could not be established because of their similar endoscopic aspect); (ii) previous pathological examination showing superficial colorectal tumor, including adenoma, intramucosal carcinoma, or those with submucosal invasion of less than 1000 μm in depth; and (iii) a lesion without invasion upon macroscopic endoscopic evaluation using the Paris morphological14 and Kudo classifications15.
Endoscopic resection for colon tumor
15
Exclusion criteria were: (i) colorectal carcinoma with submucosal invasion of deeper than 1000 μm upon previous histological examination; and (ii) a positive invasive pattern upon macroscopic endoscopic evaluation. Technique for colorectal ESD All patients were admitted the day before ESD for bowel preparation with 2 L polyethylene glycol electrolyte solution. Conscious sedation was performed intravenously using a combination of hydroxyzine and pethidine in all cases. Carbon dioxide insufflation was systematically used. Four endoscopists, who had performed more than 100 ESD, performed the procedures. Instruments for colorectal ESD
Endoscopic system and electrosurgical generator A single-channel endoscope (CF-240I; Olympus, Tokyo, Japan) was used. A 4-mm-long transparent hood was systematically attached to the tip of the endoscope (D-201-13404; Olympus) to facilitate optimal field visualization and stable dissection. A small–caliber-tip transparent hood (ST hood) (DH-16CR; Fujinon Optical, Tokyo, Japan) was used, a narrow-tip hood used to facilitate the entry of endoscopic devices into the submucosal layer, particularly in cases with severe fibrosis. A VIO 300 D (Erbe Elektromedizin, Tübingen, Germany) electrosurgical generator was used during the ESD procedures.
Devices used during ESD Flush knife (DK-2618JN; Fujinon Optical) was used for all patients.16 This is a short needle knife with special characteristics that comes in a diameter of 0.5 mm and needle lengths of 1.0, 1.5 or 2.0 mm. This knife allows for greater flexibility in the angle of insertion than the conventional needle knife and can dissect severe fibrosis. In patients with severe submucosal fibrosis, the knife with a length of 1.0 mm was preferentially used. This standard Flush knife was used at the beginning of the study, and ESD was then performed using a ball-tipped needle knife (Flush knife-BT), which is equipped with a spherical tip 0.9 mm in diameter and lengths ranging between 1.5 and 2.0. This more recently designed Flush knife-BT was developed to improve the hemostatic capabilities
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
16
G Rahmi et al.
of the standard Flush knife.17 Saline solution was flushed down the device sheath alongside the needle to enable improved submucosal lifting using a flushing pump (FTS JW-2; Fujinon) without the need for additional injection; however, the flushing does not cut or dissect the submucosal layer because the pressure is relatively low (0.3 MPa).
Journal of Digestive Diseases 2015; 16; 14–21
Marking Marking of the colorectal tumors was not usually necessary because the limit between the lesions and normal mucosa was quite clear after spraying the mucosa with indigo carmine.
Local injection Colorectal ESD technique The ESD procedure for colorectal tumors is shown in Fig. 1.
Sodium hyaluronate was initially injected into the submucosal layer in all cases to lift the lesion, allowing for good surveillance of the lesion. During the procedure, saline solution was injected from the Flush knife. Some cases with severe fibrosis required additional sodium hyaluronate injection via a standard injection needle.
Mucosal incision Mucosal incision was performed approximately 5 mm outside the edges of the tumors. The Flush knife at 1.5 mm was used for the mucosal incision, starting at the anal side. An additional incision was performed from the anal side to the oral side to create a circumferential incision.
Submucosal dissection The Flush knife was used at 1.5 mm except in cases of severe fibrosis (1.0 mm) and when a parallel approach to the muscle layer was difficult. An additional dissection was performed after appropriate local injection. Management of eventual complications
Hemostasis and vessel coagulation
Figure 1. Endoscopic submucosal dissection (ESD) for colorectal tumors. (a) Residual lesion in the sigmoid colon. This lesion has received endoscopic mucosal resection four times previously. (b) Lateral spreading tumor nodular mixed type lesion 43 mm in size. (c) Severe fibrosis is found at the center of the lesion. (d) The area with severe fibrosis can be dissected with a 1.0-mm Flush knife needle. (e) Ulcer bed after resection. (f) Pathological diagnosis of mucosal cancer with severe fibrosis.
Meticulous hemostasis was applied during the procedure. Diffuse bleeding (or oozing) was generally treated with the tip of the knife with forced coagulation. Pulsating bleeding points and thick vessels were grasped and retracted with a hemostatic forceps (Coagrasper, FD-411QR; Olympus) with soft coagulation. At the end of the procedure, each vessel visible in the base of the mucosal defect after the procedure was coagulated.
Perforation Immediate perforation was recognized during the procedure and treated by endoscopic clipping. Patients were also fasted and received antibiotics. Abdominal
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Journal of Digestive Diseases 2015; 16; 14–21 computed tomography (CT) was performed after ESD, and clinical examinations were completed every day during hospitalization. Delayed perforations were treated surgically. Histopathological assessment The resected specimens were collected intact, stretched and pinned out, fixed in formalin, cut into 2-mm sections and assessed microscopically. En bloc resection was defined as a tumor removed in a single piece. That resected as a single piece in the absence of lateral or deep margin invasions was regarded as en bloc R0 resection. En bloc R0 curative resection was defined as follows: (i) adenoma; (ii) intramucosal well-differentiated carcinoma; and (iii) minimally invasive submucosal well-differentiated carcinoma (submucosal invasion less than 1000 μm in depth) without lymphovascular invasion. Endoscopic follow-up The curatively resected cases were followed up with endoscopic examinations one year after ESD. Biopsy samples were taken if a recurrent tumor was visible upon chromoscopy. Statistical analysis Statistical analyses were performed using SPSS 18.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation (SD) or medians and ranges and categorical parameters were expressed as numbers and frequencies. The efficacy of ESD was evaluated via the en bloc R0 curative rate. Factors potentially affecting the operating time and reflecting the difficulty of the procedure (operating time ≥90 min) were: tumor size, lesion location (left colon, right colon or rectum), macroscopic type (granular lateral spreading tumor or non-granular lateral spreading tumor), previous resection (number of EMR before ESD), and depth of invasion upon histological examination. Fisher’s exact test was used for descriptive analysis. P ≤ 0.05 were considered statistically significant. RESULTS Characteristics of the patients and lesions Altogether 28 patients were found to have locally recurrent or residual colorectal lesions, including 15
Endoscopic resection for colon tumor
17
men. The mean age of the patients was 66.5 ± 9.0 years. ESD was performed in 27 of the 28 patients. ESD was technically impossible for the remaining patient with severe fibrosis who was referred to a surgeon. The clinicopathological features of the patients and the tumors are detailed in Table 1. The lesions were essentially localized at the distal colon and rectum, with a mean tumor size of 38 mm (range 10–180 mm). The mean procedure time was 63 min (range 22–248 min). Tumors showed non-lifting signs because of submucosal fibrosis in all the patients. A standard Flush knife was used at the beginning of the procedure, and a Flush knife-BT was used for most patients. For six patients, two needles with different lengths were used during the procedure. Endoscopic characteristics during ESD are shown in Table 2. Patients’ outcomes and histopathology of the lesions Complete en bloc resection was achieved in 96.4% (27/28) of the patients (Fig. 2). At the end of the procedure, macroscopic complete resection was achieved in all the patients. After histological examination, en bloc R0 curative resection rate was confirmed to be 92.9% (26/28). One 60-year-old male patient who was treated for a 40-mm lesion at the transverse colon had an invasive cancer with deep infiltration in the submucosa (>3000 μm in depth). This patient was referred for surgical treatment. Histological examination showed curative resection in the other 26 cases (one carcinoid tumor, eight adenomas with dysplasia and 17 well-differentiated carcinomas without lymphovascular involvements). Table 1. Characteristics of patients treated for residual or locally recurrent colorectal lesions (n = 28) Male, n (%) Age, years (mean ± SD) Time between previous resection and ESD, months (median [range]) Location of tumors, n Caecum/ascendant colon/transverse colon Descendant colon/sigmoid/rectum Macroscopic tumor aspect, n 0–I pedunculated/sessile 0–IIa/0–IIb/0–IIc Lateral spreading tumor Granular/non-granular Submucosal tumor
15 (53.6) 66.5 ± 9.0 24 (4–41)
2/2/7 2/8/7 0/3 8/0/1 7/8 1
ESD, endoscopic submucosal dissection; SD, standard deviation.
© 2014 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
18
G Rahmi et al.
Journal of Digestive Diseases 2015; 16; 14–21
Table 2. Endoscopic characteristics during endoscopic submucosal dissection in patients treated for residual or locally recurrent colorectal lesions (n = 28) Flush knife (mm), n Ball-tipped: 2/1.5 Needle tip: 2/1.5/1 Ancillary device, n ST hood Resection type, n En bloc Failure Piecemeal Operating time, min (median [range]) Size of tumor, mm (median [range]) Size of specimen, mm (median [range]) Bleeding, n Perforation, n Immediate Delayed Length of hospital stay, days (median [range])
12/10 0/5/6 3 27 1 0 63 (22–248) 17.5 (4–68) 38 (10–180) 0 0 1 7 (6–24)
Table 3. Factors potentially affecting the operating time and reflecting the difficulty of the procedure Operating time n (%)
