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

Abstract

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 cm²/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 cm²/h) and the last study period (10.8 cm²/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.

• References

• 1 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 2 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 3 Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 1993; 25: 455-461
• 4 Saito Y, Fujii T, Kondo H. et al. Endoscopic treatment for laterally spreading tumors in the colon. Endoscopy 2001; 33: 682-686
• 5 Arebi N, Swain D, Suzuki N. et al. Endoscopic mucosal resection of 161 cases of large sessile or flat colorectal polyps. Scand J Gastroenterol 2007; 42: 859-866
• 6 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
• 7 Yamada M, Saito Y, Takamaru H. et al. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017; 49: 233-242
• 8 Probst A, Ebigbo A, Markl B. et al. Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center. Endoscopy 2017; 49: 222-232
• 9 Sauer M, Hildenbrand R, Oyama T. et al. Endoscopic submucosal dissection for flat or sessile colorectal neoplasia > 20 mm: A European single-center series of 182 cases. Endosc Int Open 2016; 4: E895-900
• 10 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
• 11 Repici A, Hassan C, De Paula PessoaD. et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy 2012; 44: 137-150
• 12 Gondal G, Grotmol T, Hofstad B. et al. Biopsy of colorectal polyps is not adequate for grading of neoplasia. Endoscopy 2005; 37: 1193-1197
• 13 Absar MS, Haboubi NY. Colonic neoplastic polyps: biopsy is not efficient to exclude malignancy. The Trafford experience. Tech Coloproctol 2004; 8 Suppl 2: s257-260
• 14 Toyonaga T, Man-i M, East JE. et al. 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. Surg Endosc 2013; 27: 1000-1008
• 15 Niimi K, Fujishiro M, Kodashima S. et al. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 2010; 42: 723-729
• 16 Draganov PV, Coman RM, Gotoda T. Training for complex endoscopic procedures: how to incorporate endoscopic submucosal dissection skills in the West?. Expert Rev Gastroenterol Hepatol 2014; 8: 119-121
• 17 Ma MX, Bourke MJ. Endoscopic submucosal dissection in the West: Current status and future directions. Dig Endosc 2018; 30: 310-320
• 18 Fuccio L, Hassan C, Ponchon T. et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86: 74-86 e17
• 19 Saito Y, Bhatt A, Matsuda T. Colorectal endoscopic submucosal dissection and its journey to the West. Gastrointest Endosc 2017; 86: 90-92
• 20 Committee AT, Hwang JH, Konda V. et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
• 21 Committee AT, Maple JT, Abu DayyehBK. et al. Endoscopic submucosal dissection. Gastrointest Endosc 2015; 81: 1311-1325
• 22 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
• 23 Spychalski M, Skulimowski A, Dziki A. et al. Colorectal endoscopic submucosal dissection (ESD) in the West - when can satisfactory results be obtained? A single-operator learning curve analysis. Scand J Gastroenterol 2017; 52: 1442-1452
• 24 Rönnow CF, Elebro J, Toth E. et al. Endoscopic submucosal dissection of malignant non-pedunculated colorectal lesions. Endoscopy International Open 2018; 6: E961-E968
• 25 [Anonymous] The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 26 Thorlacius H, Uedo N, Toth E. Implementation of endoscopic submucosal dissection for early colorectal neoplasms in Sweden. Gastroenterol Res Pract 2013; 2013: 758202
• 27 Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut 2002; 51: 130-131
• 28 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213
• 29 Hassan C, Quintero E, Dumonceau JM. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
• 30 Hotta K, Oyama T, Shinohara T. et al. Learning curve for endoscopic submucosal dissection of large colorectal tumors. Dig Endosc 2010; 22: 302-306
• 31 Sakamoto T, Saito Y, Fukunaga S. et al. Learning curve associated with colorectal endoscopic submucosal dissection for endoscopists experienced in gastric endoscopic submucosal dissection. Dis Colon Rectum 2011; 54: 1307-1312
• 32 Shiga H, Ohba R, Matsuhashi T. et al. Feasibility of colorectal endoscopic submucosal dissection (ESD) carried out by endoscopists with no or little experience in gastric ESD. Dig Endosc 2017; 29: 58-65
• 33 Fuccio L, Repici A, Hassan C. et al. Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. Gut 2018; 67: 1464-1474
• 34 Hori K, Uraoka T, Harada K. et al. Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum. Endoscopy 2014; 46: 862-870
• 35 Isomoto H, Nishiyama H, Yamaguchi N. et al. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 2009; 41: 679-683
• 36 Oyama T, Yahagi N, Ponchon T. et al. How to establish endoscopic submucosal dissection in Western countries. World J Gastroenterol 2015; 21: 11209-11220
• 37 Tanaka S, Oka S, Kaneko I. et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66: 100-107
• 38 Hayashi N, Tanaka S, Nishiyama S. et al. Predictors of incomplete resection and perforation associated with endoscopic submucosal dissection for colorectal tumors. Gastrointest Endosc 2014; 79: 427-435
• 39 Imai K, Hotta K, Yamaguchi Y. et al. Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training. Gastrointest Endosc 2016; 83: 954-962
• 40 Ohya T, Marsk R, Pekkari K. Colorectal ESD in day surgery. Surg Endosc 2017; 31: 3690-3695
• 41 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
• 42 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
• 43 Coda S, Oda I, Gotoda T. et al. Risk factors for cardiac and pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment. Endoscopy 2009; 41: 421-426
• 44 Ono S, Fujishiro M, Niimi K. et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-665
• 45 Katada C, Muto M, Manabe T. et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003; 57: 165-169
• 46 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
• 47 Ohara Y, Toyonaga T, Tanaka S. et al. Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms. Endoscopy 2016; 48: 62-70
• 48 Hayashi T, Kudo SE, Miyachi H. et al. Management and risk factor of stenosis after endoscopic submucosal dissection for colorectal neoplasms. Gastrointest Endosc 2017; 86: 358-369