Dig Dis Sci DOI 10.1007/s10620-016-4036-2

CASE REPORT

Feasibility of Simple Traction Technique for Rectal Endoscopic Submucosal Dissection Yasushi Yamasaki1 • Yoji Takeuchi1 • Noriya Uedo1 • Minoru Kato1 • Kenta Hamada1 • Yusuke Tonai1 • Noriko Matsuura1 • Takashi Kanesaka1 • Tomofumi Akasaka1 • Noboru Hanaoka1 • Koji Higashino1 • Ryu Ishihara1 • Hiroyasu Iishi1

Received: 20 November 2015 / Accepted: 9 January 2016 Ó Springer Science+Business Media New York 2016

Abstract Background and Aims Rectal endoscopic submucosal dissection (ESD) is a highly effective procedure that achieves high en bloc resection regardless of lesion size or location. However, rectal ESD has a higher risk of intraoperative and postoperative bleeding and still difficult for beginners. Therefore, we designed a novel traction technique ‘‘traction-assisted rectal ESD using a clip-with-line (TAREC),’’ and investigated its feasibility. Methods Between December 2014 and July 2015, ten patients with rectal neoplasms (median size 36 mm; range 20–125 mm) were treated using the TAREC technique. Results In all lesions, good visibility of the submucosal layer was obtained, and the submucosal layer was dissected easily under direct visualization. All lesions were removed en bloc, and there were no procedure-related adverse events including postoperative bleeding. In particular, we experienced no intraoperative bleeding, which may be difficult to stop in some circumstances. Conclusions The TAREC technique is a simple and generally applicable procedure. This technique is feasible for rectal ESD. Keywords with-line

Traction  Rectal neoplasms  ESD  Clip-

Electronic supplementary material The online version of this article (doi:10.1007/s10620-016-4036-2) contains supplementary material, which is available to authorized users. & Yoji Takeuchi [email protected] 1

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan

Introduction Colorectal endoscopic submucosal dissection (ESD) is a minimally invasive and highly effective procedure that achieves a high en bloc resection rate regardless of lesion size or location [1]. Rectal ESD is technically easier than colon ESD and less invasive than surgical operation in general, so it should be performed all over the world. However, it has a higher risk of intraoperative and postoperative bleeding because of abundant vessels, and it is not commonly widespread [1]. Intraoperative bleeding is difficult to control in some cases of rectal ESD, resulting in a time-consuming procedure. Thus, rectal ESD has been still regarded as a complicated procedure, especially in Western countries [2, 3]. Therefore, epoch-making device to reduce the difficulty of rectal ESD has been expected. The main reason why rectal ESD is not easy is that the mucosa cannot be lifted as in surgery. If the mucosa is lifted, good visibility of the submucosa is obtained and the vessels of the submucosa would be obvious. This allows for dissection of the appropriate portion of the submucosa and avoidance of intraoperative bleeding. Oyama et al. [4] recently developed a traction-assisted ESD method using an endoclip and line, termed the ‘‘clipwith-line’’ method [4]. This method lifts the mucosa and enables maintenance of good visualization of the submucosal layer during ESD, which makes ESD easier to perform. This method is very useful, but it is mainly applied to esophageal or gastric ESD, even in Japan. We found that this method is applicable to rectal ESD and may make rectal ESD easier. The aims of this study were to evaluate the feasibility of traction-assisted rectal ESD using the clip-with-line (TAREC) technique.

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Patients and Methods From December 2014 to July 2015, 29 patients underwent rectal ESD at the Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan. Rectal ESD was performed for rectal laterally spreading tumors larger than 20 mm because the Japanese guidelines for treatment of colorectal cancer suggested that 20 mm is the largest size of a tumor that can be easily resected en bloc by conventional endoscopic mucosal resection (EMR) [5, 6]. Among 29 patients, 10 patients underwent TAREC technique according to operators’ preference in our institution and included in this study. Lesions showing evidence of deep submucosal invasion (C1000 lm) or lesions with previous EMR attempts were excluded. All the patients were admitted to hospital. This study was approved by the institutional review board, and written informed consent was obtained from all individual participants. Measurement outcomes were the en bloc resection rate, complete en bloc resection (R0 resection) rate, procedure time, and adverse events. R0 resection was defined as en bloc resection without identification of a tumor at the lateral or vertical margin. The procedure time was measured from the start of the submucosal injection until removal of the lesion. Intraoperative uncontrolled bleeding was defined as severe hemorrhage accompanied by instability of vital sign or achieved endoscopic hemostasis over 10 min during the ESD. Postoperative bleeding was defined as blood in the rectum or stigmata of a recent hemorrhage at the ulcer base that required endoscopic hemostasis, or hematochezia accompanied by either instability of vital sign or reduction in hemoglobin level of greater than 2 g/dl within 24 h after the ESD. Perforation was defined as full-thickness defect of the colonic wall or the presence of extra-gastrointestinal air on abdominal computed tomography (CT) scan. Histopathological diagnoses were made according to the Japanese classification [7]. Basically, all the patients undergone TAREC were planned to visit our office about 2 weeks after their endoscopic therapy for the assessment of post-procedural complications such as bleeding and abdominal pain.

opening the endoclip at this moment. The clip and line were then retracted into the applicator as in preparation before rectal ESD. Next, the colonoscope was inserted into the rectum as usual, and the actual procedure was started. All rectal ESD procedures were performed using a 1.5-mm FlushKnife (DK2618JN15; Fujifilm Medical, Tokyo, Japan), and 0.9 % saline solution was used as the water-jet fluid. An electrosurgical generator (VIO 300D; ERBE, Tu¨bingen, Germany) was used for all ESD procedures. The electrical power setting of the generator for the FlushKnife was as follows. Mucosal incision: endo-cut I mode Effect 2, duration 3, interval 3; submucosal dissection: forced-coagulation mode Effect 2, 40 W. First, 0.4 % hyaluronate sodium solution (MucoUp; Johnson and Johnson K.K., Tokyo, Japan) was injected into the submucosa. A mucosal incision on the anal side of the lesion was then performed. After the mucosal incision, the colonoscope was withdrawn outside of the rectum. The applicator, to which the clip and line were mounted, was inserted into the accessory channel of the colonoscope, and the line was pulled back up through the working channel of the colonoscope (Video 1). Then the colonoscope was reinserted into the rectum (Fig. 2). The endoclip was fully opened within the rectum and used to grasp the anal side of the lesion (Fig. 3, Video 1). Next, the line was gently pulled to create traction, resulting in good visibility of the submucosal layer (Fig. 4, Video 1). After completion of the circumferential mucosal incision, the submucosal layer was dissected easily under direct visualization. Multiple ‘‘clip-with-line’’ can be applied on demand, especially for large lesions.

Results The patient and lesion characteristics and the treatment details are shown in Table 1. The patients comprised nine women and one man with a median age of 73.5 years (range

Traction-Assisted Rectal ESD Using a Clip-withLine (TAREC) Technique Rectal ESD was conducted using a colonoscope (PCFQ260AZI, PCF-Q260JI, or CF-Q260DI; Olympus, Tokyo, Japan) with a distal attachment cap (D-201-13404 or D-201-11804; Olympus). The TAREC technique was performed as follows. First, a 3-0 polyester line 0.25 mm in diameter was tied to the teeth of an endoclip (HX-610-090; Olympus), which was attached to an applicator, without any bonding agent (Fig. 1). Importantly, we avoided fully

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Fig. 1 Polyester line tied to the teeth of an endoclip

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Fig. 2 Clip and line inserted into the accessory channel of the colonoscope, and the colonoscope reinserted into the rectum

Fig. 4 Line was pulled gently, the mucosa was lifted, and good visibility of the submucosal layer was obtained. The submucosal vessels were obvious

continued by means of a semiannual CT scan and annual colonoscopy. The other lesion had invaded the submucosa 3000 lm at least with lymphovascular invasion, and the vertical margin of the lesion was unclear on histological examination because of the deeply invaded adenocarcinoma. The patient underwent additional surgical resection. Followup colonoscopy 1 year after TAREC will be performed in other eight lesions. The median follow-up period was 7 months (range 5–12 months). There was no recurrence at present.

Fig. 3 Clip fully opened to grasp the anal side of the lesion

55–85 years). The median lesion size was 36 mm (range 20–125 mm). All lesions were removed en bloc using the TAREC technique. The median procedure time was 75 min (range 31–174 min.). No perforation or postoperative bleeding occurred in any of the ten patients. The median hospital stay was 7 days (range 6–7 days). R0 resections were performed in nine of ten (90 %) lesions. Pathological examination revealed nine adenocarcinomas and one tubulovillous adenoma. Two lesions had deeply invaded the submucosa (C1000 lm). Among the two lesions, one lesion had invaded the submucosa 1100 lm without lymphovascular invasion. According to the Japanese guidelines for treatment of colorectal cancer [5], the patient was recommended to undergo additional surgical resection, but the patient refused to undergo surgery. Six months after TAREC, no recurrence was found using colonoscopy and contrastenhanced computed CT scan. Careful follow-up has been

Discussion Oyama et al. [4] developed traction-assisted esophageal or gastric ESD using the ‘‘clip-with-line’’ technique. The usefulness of traction-assisted esophageal or gastric ESD using the ‘‘clip-with-line’’ technique has been reported in several Asian countries [4, 8, 9]. However, the usefulness of this method for rectal ESD has rarely been reported. We applied this method to rectal ESD, and all lesions in our trial were successfully resected en bloc. In all cases, good visibility of the submucosal layer was obtained, and the submucosal layer was dissected easily under direct visualization without perforation. In particular, the submucosal vessels were obvious in all cases; thus, we experienced no intraoperative bleeding, which may be difficult to stop in some circumstances. Additionally, the TAREC makes visualization of muscular layer better and can decrease the risk of perforation. Endoscopic piecemeal mucosal resection (EPMR) for large rectal neoplasms is a relatively quick and easy

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Dig Dis Sci Table 1 Patient characteristics and treatments No.

Age, sex

Location

Type

Size (mm)

Procedure time (min)

1

67, F

RS

LST-G

20

2

73, F

Ra

LST-G

65

90

Yes

Yes

Tis

No

No

3

80, F

RS–Ra

LST-G

60

160

Yes

Yes

Tis

No

No

55

En bloc resection

R0 resection

Histology

Lymphovascular invasion

Adverse eventsa

Yes

Yes

Tis

No

No

4

74, F

Rb

LST-G

66

95

Yes

Yes

Tis

No

No

5b

75, F

Rb

LST-NG

30

60

Yes

Yes

T1bc

No

No

6

85, M

Rb

LST-G

22

31

Yes

Yes

TVA

No

No

e

d

7 8

75, F 55, F

Rb RS–S

LST-G LST-G

38 125

90 174

Yes Yes

No Yes

T1b Tis

Yes No

No No

9

64, F

Ra

LST-G

34

43

Yes

Yes

Tis

No

No

10

57, F

Rb

LST-G

27

31

Yes

Yes

Tis

No

No

S, sigmoid colon; RS, rectosigmoid; Ra, upper rectum; Rb, lower rectum; LST-G, laterally spreading tumor, granular type; LST-NG, laterally spreading tumor, nongranular type; Tis, carcinoma in situ; T1b, deeply submucosal invasive cancer (C1000 lm); TVA, tubulovillous adenoma a

Adverse events included intraoperative uncontrolled bleeding, postoperative bleeding, and perforation

b

No. 5 patient was recommended to undergo additional surgical resection, but she refused additional surgery. Six months after the TAREC, colonoscopy and abdominal contrast-enhanced computed tomography scans showed no evidence of local recurrence or distant metastasis

c

T1b, the tumor invaded the submucosa 1100 lm

d

No. 7 patient underwent additional surgical resection

e

T1b, the tumor invaded the submucosa 3000 lm

procedure, but it is associated with a higher risk of local recurrence [10]. Therefore, EPMR requires a strict followup schedule. Although laparoscopic-assisted rectal surgery (LAR) is more radical than EPMR and relatively less invasive than open surgery, LAR is associated with a higher incidence of severe adverse events such as wound infection, pelvic abscess formation, and anastomosis leakage than is endoscopic resection. Additionally, temporary or permanent stomas are necessary in some cases of LAR [11]. Furthermore, the sequela of surgical rectal resection disturbs patients’ quality of life. Transanal endoscopic microsurgery (TEM) is a promising local resection technique for rectal tumors and is performed by experienced surgeons. TEM involves local full-thickness resection and closure for early rectal cancer and is known to be highly effective and has a low complication rate [12]. However, TEM requires general anesthesia and special equipment, and it is limited by the location of the lesion [12]. So, TEM is still complicated than endoscopic resection. Thus, development of simple, more reliable and less invasive local resection techniques for large rectal neoplasms is urgently needed. ESD has the advantages of a high en bloc resection rate, minimal invasiveness, and avoidance of anesthesia, and it can be applied to lesions located anywhere in the rectum, even for those at the rectosigmoid junction (Table 1). However, rectal ESD is still considered a technically difficult procedure all over the world, in spite of generalization in Japan. Although several other traction methods for rectal ESD using special equipment have been

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reported in Asian and Western countries [2, 13], and although these methods might provide adequate traction and a clear field of vision, they are a bit complicated and not as widespread. The technique described herein is a simple traction technique without the need for special devices or equipment, and it is generally applicable worldwide. In our institution, 98 conventional rectal ESD were performed from January 2011 to January 2014. The median lesion size was 33 mm (range 10–115 mm), and the median procedure time was 85 min (range 23–480 min.). R0 resections were performed in 84 of 98 (85 %) lesions. Postoperative bleeding occurred in four patients (4 %). Although there was no statistically significant difference in the procedure time, R0 resection rate, and postoperative bleeding rate between 98 conventional rectal ESD and 10 TAREC, the procedure time was tend to shorten in TAREC. Actually, the median procedure time in this trial was longer than that of our previous report in which two experienced endoscopists performed all colorectal ESD [14]. Four lesions in this trial were huge rectal neoplasms of [6 cm in size, and it is not comparable with previous report. However, while huge colorectal neoplasms of [5 cm in size were reported to be time-consuming and a risk factor for adverse events [15], R0 resection without adverse events were achieved in our four huge lesions. In addition, most of the lesions in this trial were treated by endoscopic fellows under direct supervision of experienced endoscopists. Thus, in our trial, TAREC technique may be

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technically easier and enable a high en bloc resection rate regardless of lesion size or endoscopists’ experience. Of course, because this pilot trial involved a small sample size in a retrospective design, and the patients were included in this trial according to operators’ preference, further studies are required to show the applicability of the present data to other settings. In summary, traction-assisted rectal ESD using the clipwith-line technique seems feasible and safe. Our findings should be further evaluated in prospective randomized controlled trials.

6.

7.

8.

9.

Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest associated with this manuscript.

10.

11.

References 1. Takeuchi Y, Iishi H, Tanaka S, et al. Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort. Int J Colorectal Dis. 2014;29:1275–1284. 2. Saunders BP, Tsiamoulos ZP, Thomas H, et al. Rectal endoscopic submucosal dissection made easy: a solution to the retraction problem. Gastroenterology. 2013;145:939–941. 3. Repici A, Hassan C, Pagano N, et al. High efficacy of endoscopic submucosal dissection for rectal laterally spreading tumors larger than 3 cm. Gastrointest Endosc. 2013;77:96–101. 4. Oyama T. Counter traction makes endoscopic submucosal dissection easier. Clin Endosc. 2012;45:375–378. 5. Watanabe T, Itabashi M, Shimada Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for

12.

13.

14.

15.

treatment of colorectal cancer. Int J Clin Oncol. 2015;20:207–239. Tanaka S, Oka S, Chayama K. Colorectal endoscopic submucosal dissection (ESD): the present status and future perspective including its differentiation from endoscopic mucosal resection (EMR). J Gastroenterol. 2008;43:641–651. Japanese Society for Cancer of the Colon and Rectum. Japanese classification of colorectal carcinoma. 2nd English ed. Tokyo: Kanehara and Co Ltd; 2009. Jeon WJ, You IY, Chae HB, et al. A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection. Gastrointest Endosc. 2009;69:29–33. Koike Y, Hirasawa D, Fujita N, et al. Usefulness of the threadtraction method in esophageal endoscopic submucosal dissection: randomized controlled trial. Dig Endosc. 2015;27:303–309. Oka S, Tanaka S, Saito Y, et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol. 2015;110:697–707. Kiriyama S, Saito Y, Yamamoto S, et al. Comparison of endoscopic submucosal dissection with laparoscopic-assisted colorectal surgery for early-stage colorectal cancer: a retrospective analysis. Endoscopy. 2012;44:1024–1030. Park SU, Min YW, Shin JU, et al. Endoscopic submucosal dissection or transanal endoscopic microsurgery for nonpolypoid rectal high grade dysplasia and submucosa-invading rectal cancer. Endoscopy. 2012;44:1031–1036. Uraoka T, Kato J, Ishikawa S, et al. Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos). Gastrointest Endosc. 2007;66:836–839. Takeuchi Y, Uedo N, Ishihara R, et al. Efficacy of an endo-knife with a water-jet function (Flushknife) for endoscopic submucosal dissection of superficial colorectal neoplasms. Am J Gastroenterol. 2010;105:314–322. Saito Y, Uraoka T, Yamaguchi Y, et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc. 2010;72:1217–1225.

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Feasibility of Simple Traction Technique for Rectal Endoscopic Submucosal Dissection.

Rectal endoscopic submucosal dissection (ESD) is a highly effective procedure that achieves high en bloc resection regardless of lesion size or locati...
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