Endosc Int Open 2017; 05(09): E839-E846
DOI: 10.1055/s-0043-113566
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty

Federico Iacopini1, Yutaka Saito2, Antonino Bella3, Takuji Gotoda4, Patrizia Rigato5, Walter Elisei1, Fabrizio Montagnese1, Giampaolo Iacopini6, Guido Costamagna7
  • 1Gastroenterology Endoscopy Unit, Ospedale S. Giuseppe, Albano Laziale, Rome, Italy
  • 2Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
  • 3National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
  • 4Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
  • 5Pathology Unit, Ospedale S. Giuseppe, Marino, Rome, Italy
  • 6Private Practice, Via Merulana, Rome, Italy
  • 7Surgical Endoscopy Unit, Policlinico Agostino Gemelli, Catholic University, Rome, Italy
Further Information

Publication History

submitted 25 November 2016

accepted after revision 19 May 2017

Publication Date:
12 September 2017 (online)

Abstract

Background and study aim The role of colorectal endoscopic submucosal dissection (ESD) is standardized in Japan and East Asia, but technical difficulties hinder its diffusion. The aim was to identify predictors of difficulty for each neoplasm type.

Methods A competent operator performed all procedures. ESD difficulty was defined as: en bloc with a slow speed (< 0.07 cm2/min; 30 × 30 mm neoplasm in > 90 min), conversion to endoscopic mucosal resection, or resection abandonment. Pre- and intraoperative difficulty variables were defined according to standard criteria, and evaluated separately for the rectum and colon. Difficulty predictors and gradients were evaluated by the multivariate logistic regression model.

Results A total of 140 ESDs were included: 110 in the colon and 30 in the rectum. Neoplasms were laterally spreading tumors – granular type (LST-G) in 85 cases (61 %); the median longer axis was 30 mm (range 15 – 180 mm); a scar was present in 15 cases (11 %). ESD en bloc resection and difficulty rates were 85 % (n = 94) and 35 % (n = 39) in the colon, and 73 % (n = 22) and 50 % (n = 15) in the rectum (P = 0.17 and 0.28, respectively). The scar was the only preoperative predictor of difficulty in the rectum (odds ratio [OR] 12.3, 95 % confidence interval [CI] 1.27 – 118.36), whereas predictors in the colon were: scar (OR 12.7, 95 %CI 1.15 – 139.24), LST – nongranular type (NG) (OR 10.5, 95 %CI 1.20 – 55.14), and sessile polyp morphology (OR 3.1, 95 %CI 1.18 – 10.39). Size > 7 – ≤ 12 cm2 (OR 0.20, 95 %CI 0.06 – 0.74) and operator experience > 120 procedures (OR 0.19, 95 %CI 0.04 – 0.81) were predictors for a easy procedure. No intraoperative predictors of difficulty were identified in the rectum, whereas predictors in the colon were: severe submucosal fibrosis (OR 21.9, 95 %CI 2.11 – 225.64), ineffective submucosal exposure by gravity countertraction (OR 12.3, 95 %CI 2.43 – 62.08), and perpendicular submucosal dissection approach (OR 5.2, 95 %CI 1.07 – 25.03). When experience was /= 90, preoperative gradient of colonic ESD difficulty was the highest for LST-NGs (scar positive and negative up to 47 % and 20 %, respectively), intermediate for sessile polyps with scar (up to 23 %), and the lowest for LST-Gs (< 8 %). Different difficulty gradients between neoplasm types persisted with increasing experience: LST-NG rate up to 14 % after 120 procedures.

Conclusions Colonic and rectal ESD difficulty has qualitative differences. Preoperative predictors should be considered to identify the difficulty gradient of each neoplasm type and the appropriate setting for ESD.