Endoscopic Submucosal Dissection (ESD) for the management of Fibrotic Non-lifting Colorectal Lesions (NLCs): results from a large multicenter retrospective study

Aims Non-lifting colorectal lesions (NLCLs), often resulting from previous unsuccessful treatments or biopsies, are challenging to treat due to submucosal fibrosis. Various endoscopic techniques have been proposed for their management; however no standard approach has been established. This study aimed to assess the feasibility, effectiveness, and safety of endoscopic submucosal dissection (ESD) for these lesions, including cases requiring conversion to hybrid-ESD (H-ESD), when performed by experienced endoscopists in tertiary referral centers.

Methods We performed a retrospective analysis of prospective collected data of all consecutive patients diagnosed with NLCLs with submucosal fibrosis at two italian tertiary referral centers from January 2009 to September 2022. The fibrosis degree of lesions was classified during the index procedure as F1 or mild and F2 or severe [1]. All procedures were performed by expert operators, defined as those having completed at least 100 colorectal ESDs and regularly receiving referrals from other hospitals. The primary endpoint was the recurrence rate, while secondary endpoints included adverse events (AEs) rate, technical success (TS) rate (en bloc resection regardless of technique), complete resection (CR) and curative resection (cR) rates, surgical intervention rate, and features associated with outcomes.

Results 178 patients with NLCLs were included (52 previously biopsied, 126 recurrent after previous resection). ESD was used in 111 (62.4%) and H-ESD in 67 (37.6%) cases. During a median follow-up of 373 days (IQR 540), the overall recurrence rate was 3.6%, all treated by endoscopy. The overall AE rate was 13.4%, and perforation was the most frequent (8.4%), without significant differences between ESD and H-ESD (p=0.53). All AEs were successfully managed endoscopically, while 6.1% of patients were referred for surgery, only due to malignant histology The TS rate was 71.9%, significantly higher in previously biopsied lesions compared to recurrent ones (78.8% vs. 55.6%, p=0.04). On multivariate analysis rectal location (p<0.001), F1 fibrosis (p=0.026), and previously biopsied lesions (p=0.006) predicted ESD TS without the need for conversion to H-ESD.

Conclusions ESD/H-ESD approach is feasible and safe for NLCLs when performed by experienced operators. Previously biopsied lesions, rectal localization, and lower fibrosis grades were associated with higher TS rates.

Publication History

Article published online:
27 March 2025

• References

• 1 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scandinavian Journal of Gastroenterology 2010; 45: 1329-1337