Management of colorectal laterally spreading tumors: a systematic review and meta-analysis

Abstract

Objective and study aims To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST).

Methods Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model.

Results Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 – 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 – 92.9 %, I² = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 – 95.5 %, vs. 84 % 95 % CI 78.1 – 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 – 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 – 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 – 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 – 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 – 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 – 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 – 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST.

Conclusions EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.

^* Drs. Russo and Barbeiro: These authors contributed equally.

• References

• 1 Kudo S, Lambert R, Allen JI. et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc 2008; 68: S3-47
• 2 Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 1993; 25: 455-61
• 3 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 4 Urban O, Vitek P, Fojtik P. et al. Laterally spreading tumors -- experience based on 138 consecutive cases. Hepatogastroenterology 2008; 55: 351-355
• 5 Probst A, Golger D, Anthuber M. et al. Endoscopic submucosal dissection in large sessile lesions of the rectosigmoid: learning curve in a European center. Endoscopy 2012; 44: 660-667
• 6 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 7 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65: 806-820
• 8 Fujiya M, Tanaka K, Dokoshi T. et al. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81: 583-595
• 9 Wang S, Gao S, Yang W. et al. Endoscopic submucosal dissection versus local excision for early rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2016; 20: 1-9
• 10 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
• 11 Niimi K, Fujishiro M, Kodashima S. et al. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 2010; 42: 723-729
• 12 Nishiyama H, Isomoto H, Yamaguchi N. et al. Endoscopic submucosal dissection for laterally spreading tumours of the colorectum in 200 consecutive cases. Surg Endosc 2010; 24: 2881-2887
• 13 Suzuki S, Chino A, Kishihara T. et al. Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms. World J Gastroenterol 2014; 20: 1839-1845
• 14 Uraoka T, Fujii T, Saito Y. et al. Effectiveness of glycerol as a submucosal injection for EMR. Gastrointest Endosc 2005; 61: 736-740
• 15 Bae JH, Yang DH, Lee JY. et al. Clinical outcomes of endoscopic submucosal dissection for large colorectal neoplasms: a comparison of protruding and laterally spreading tumors. Surg Endosc 2016; 30: 1619-1628
• 16 Conio M, Blanchi S, Filiberti R. Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve. Endoscopy 2010; 42: 677-680
• 17 Yoshikane H, Hidano H, Sakakibara A. et al. Endoscopic resection of laterally spreading tumours of the large intestine using a distal attachment. Endoscopy 1999; 31: 426-430
• 18 Fasoulas K, Lazaraki G, Chatzimavroudis G. et al. Endoscopic mucosal resection of giant laterally spreading tumors with submucosal injection of hydroxyethyl starch: comparative study with normal saline solution. Surg Laparosc Endosc Percutan Tech 2012; 22: 272-278
• 19 Binmoeller KF, Hamerski CM, Shah JN. et al. Attempted underwater en bloc resection for large (2 – 4 cm) colorectal laterally spreading tumors (with video). Gastrointest Endosc 2015; 81: 713-718
• 20 Hulagu S, Senturk O, Korkmaz U. et al. Endoscopic submucosal dissection for colorectal laterally spreading tumors. Turk J Gastroenterol 2013; 24: 532-540
• 21 Iizuka H, Okamura S, Onozato Y et a. Endoscopic submucosal dissection for colorectal tumors. Gastroenterol Clin Biol 2009; 33: 1004-1011
• 22 Hurlstone DP, Atkinson R, Sanders DS. et al. Achieving R0 resection in the colorectum using endoscopic submucosal dissection. Br J Surg 2007; 94: 1536-1542
• 23 Kim ES, Cho KB, Park KS. et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy 2011; 43: 573-578
• 24 Berr F, Wagner A, Kiesslich T. et al. Untutored learning curve to establish endoscopic submucosal dissection on competence level. Digestion 2014; 89: 184-193
• 25 Belle S, Collet PH, Szyrach M. et al. Selective tissue elevation by pressure for endoscopic mucosal resection of colorectal adenoma: first clinical trial. Surg Endosc 2012; 26: 343-349
• 26 Kim HG, Thosani N, Banerjee S. et al. Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 2014; 80: 1094-1102
• 27 Arebi N, Swain D, Suzuki NI. et al. Endoscopic mucosal resection of 161 cases of large sessile or flat colorectal polyps. Scand J Gastroenterol 2007; 42: 859-866
• 28 Belderbos TD, Leenders M, Moons LM. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-402
• 29 Puli SR, Kakugawa Y, Saito Y. et al. Successful complete cure en-bloc resection of large nonpedunculated colonic polyps by endoscopic submucosal dissection: a meta-analysis and systematic review. Ann Surg Oncol 2009; 16: 2147-2151
• 30 Tang XW, Ren YT, Zhou JQ. et al. Endoscopic submucosal dissection for laterally spreading tumors in the rectum >/=40 mm. Tech Coloproctol 2016; 20: 437-443
• 31 Youk EG, Sohn DK, Hong CW. et al. Early Outcomes of Endoscopic Submucosal Dissection for Colorectal Neoplasms According to Clinical Indications. Dis Colon Rectum 2016; 59: 403-410
• 32 Yamada M, Saito Y, Sakamoto T. et al. Endoscopic predictors of deep submucosal invasion in colorectal laterally spreading tumors. Endoscopy 2016; 48: 456-464
• 33 Kobayashi N, Saito Y, Uraoka T. et al. Treatment strategy for laterally spreading tumors in Japan: before and after the introduction of endoscopic submucosal dissection. J Gastroenterol Hepatol 2009; 24: 1387-1392
• 34 Rotondano G, Bianco MA, Buffoli F. The Cooperative Italian FLIN Study Group: prevalence and clinico-pathological features of colorectal laterally spreading tumors. Endoscopy 2011; 43: 856-861
• 35 Imai K, Hotta K, Yamaguchi Y. et al. Should laterally spreading tumors granular type be resected en bloc in endoscopic resections?. Surg Endosc 2014; 28: 2167-2173
• 36 Cong ZJ, Hu LH, Ji JT. et al. A long-term follow-up study on the prognosis of endoscopic submucosal dissection for colorectal laterally spreading tumors. Gastrointest Endosc 2016; 83: 800-807
• 37 Horiuchi Y, Chino A, Matsuo Y. et al. Diagnosis of laterally spreading tumors (LST) in the rectum and selection of treatment: characteristics of each of the subclassifications of LST in the rectum. Dig Endosc 2013; 25: 608-614
• 38 Huang Y, Liu S, Gong W. et al. Clinicopathologic features and endoscopic mucosal resection of laterally spreading tumors: experience from China. Int J Colorectal Dis 2009; 24: 1441-1450
• 39 Byeon JS, Yang DH, Kim KJ. et al. Endoscopic submucosal dissection with or without snaring for colorectal neoplasms. Gastrointest Endosc 2011; 74: 1075-1083
• 40 Nakagoe T, Sawai T, Tsuji T. et al. Minilaparotomy approach for the resection of laterally spreading tumors of the colon. Surg Today 2004; 34: 737-74
• 41 Xu MD, Wang XY, Li QL. et al. Colorectal lateral spreading tumor subtypes: clinicopathology and outcome of endoscopic submucosal dissection. Int J Colorectal Dis 2013; 28: 63-72
• 42 Jung D, Youn YH, Jahng J. et al. Risk of electrocoagulation syndrome after endoscopic submucosal dissection in the colon and rectum. Endoscopy 2013; 45: 714-717
• 43 Facciorusso A, Antonino M, Di Maso M. et al. Non-polypoid colorectal neoplasms: Classification, therapy and follow-up. World J Gastroenterol 2015; 21: 5149-5157
• 44 Tantau AI, Tantau MV, Serban A. et al. Prevalence, histology, endoscopic treatment and long-term follow-up of large colonic polyps and laterally spreading tumors. The Romanian experience. J Gastrointestin Liver Dis 2008; 17: 419-425
• 45 Cha JM, Lim KS, Lee SH. et al. Clinical outcomes and risk factors of post-polypectomy coagulation syndrome: a multicenter, retrospective, case-control study. Endoscopy 2013; 45: 202-207
• 46 Toyonaga T, Man-i M, Fujita T. et al. Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum. Endoscopy 2010; 42: 714-722
• 47 Metz AJ, Bourke MJ, Moss A. et al. Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions. Endoscopy 2011; 43: 506-511
• 48 Jayanna M, Burgess NG, Singh R. et al. Cost Analysis of Endoscopic Mucosal Resection vs. Surgery for Large Laterally Spreading Colorectal Lesions. Clin Gastroenterol Hepatol 2016; 14: 271-278 e1-2
• 49 Sakamoto T, Sato C, Makazu M. et al. Short-term outcomes of colorectal endoscopic submucosal dissection performed by trainees. Digestion 2014; 89: 37-42
• 50 Abe S, Sakamoto T, Takamaru H. et al. Stenosis rates after endoscopic submucosal dissection of large rectal tumors involving greater than three quarters of the luminal circumference. Surg Endosc 2016; 30: 5459-5464
• 51 Hurlstone DP, Fu KI, Brown SR. et al. EMR using dextrose solution versus sodium hyaluronate for colorectal Paris type I and 0-II lesions: a randomized endoscopist-blinded study. Endoscopy 2008; 40: 110-114
• 52 Hurlstone DP, Sanders DS, Thomson M. et al. “Salvage” endoscopic mucosal resection in the colon using a retroflexion gastroscope dissection technique: a prospective analysis. Endoscopy 2006; 38: 902-906
• 53 Ritsuno H, Sakamoto N, Osada T. et al. Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S-O clip. Surg Endosc 2014; 28: 3143-3149
• 54 Mizushima T, Kato M, Iwanaga I. et al. Technical difficulty according to location, and risk factors for perforation, in endoscopic submucosal dissection of colorectal tumors. Surg Endosc 2015; 29: 133-139
• 55 Toyonaga T, Man-i M, Chinzei R. et al. Endoscopic treatment for early stage colorectal tumors: the comparison between EMR with small incision, simplified ESD, and ESD using the standard flush knife and the ball tipped flush knife. Acta Chir Iugosl 2010; 57: 41-46
• 56 Uraoka T, Ishikawa S, Kato J. et al. Advantages of using thin endoscope-assisted endoscopic submucosal dissection technique for large colorectal tumors. Dig Endosc 2010; 22: 186-191
• 57 Hisabe T, Nagahama T, Hirai F. et al. Clinical outcomes of 200 colorectal endoscopic submucosal dissections. Dig Endosc 2012; 24 (Suppl. 01) 105-109
• 58 Hotta K, Shinohara T, Oyama T. et al. Criteria for non-surgical treatment of perforation during colorectal endoscopic submucosal dissection. Digestion 2012; 85: 116-120
• 59 Okamoto K, Muguruma N, Kitamura S. et al. Endoscopic submucosal dissection for large colorectal tumors using a cross-counter technique and a novel large-diameter balloon overtube. Dig Endosc 2012; 24 (Suppl. 01) 96-99
• 60 Okamoto K, Kitamura S, Muguruma N. et al. Mucosectom2-short blade for safe and efficient endoscopic submucosal dissection of colorectal tumors. Endoscopy 2013; 45: 928-930
• 61 Nawata Y, Homma K, Suzuki Y. Retrospective study of technical aspects and complications of endoscopic submucosal dissection for large superficial colorectal tumors. Dig Endosc 2014; 26: 552-555
• 62 Makino T, Kanmura S, Sasaki F. et al. Preoperative classification of submucosal fibrosis in colorectal laterally spreading tumors by endoscopic ultrasonography. Endosc Int Open 2015; 3: E363-E367
• 63 Lee EJ, Lee JB, Choi YS. et al. Clinical risk factors for perforation during endoscopic submucosal dissection (ESD) for large-sized, nonpedunculated colorectal tumors. Surg Endosc 2012; 26: 1587-1594
• 64 Yoon JY, Kim JH, Lee JY. et al. Clinical outcomes for patients with perforations during endoscopic submucosal dissection of laterally spreading tumors of the colorectum. Surg Endosc 2013; 27: 487-493
• 65 Hong MJ, Kim JH, Lee SY. et al. Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms. Dig Dis Sci 2015; 60: 211-216
• 66 Jung DH, Youn YH, Kim JH. et al. Endoscopic submucosal dissection for colorectal lateral spreading tumors larger than 10 cm: is it feasible?. Gastrointest Endosc 2015; 81: 614-620
• 67 Zhou PH, Yao LQ, Qin XY. Endoscopic submucosal dissection for colorectal epithelial neoplasm. Surg Endosc 2009; 23: 1546-1551
• 68 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
• 69 Burgess NG, Metz AJ, Williams SJ. et al. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12: 651-661 e1 – 3
• 70 Tanaka S, Haruma K, Oka S. et al. Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. Gastrointest Endosc 2001; 54: 62-66
• 71 Tamura S, Nakajo K, Yokoyama Y. et al. Evaluation of endoscopic mucosal resection for laterally spreading rectal tumors. Endoscopy 2004; 36: 306-312
• 72 Su MY, Hsu CM, Lin CJ. et al. Endoscopic treatment of colorectal neoplasms: a simple and safe procedure to lower the incidence of colorectal cancers. Dig Dis Sci 2008; 53: 1297-1302
• 73 Hurlstone DP, Sanders DS, Cross SS. et al. Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection. Gut 2004; 53: 1334-1339
• 74 Terasaki M, Tanaka S, Oka S. et al. Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm. J Gastroenterol Hepatol 2012; 27: 734-740
• 75 Tajika M, Niwa Y, Bhatia V. et al. Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors. Eur J Gastroenterol Hepatol 2011; 23: 1042-1049