1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes

Background

Endoscopic submucosal dissection (ESD) enables en bloc resection of early gastrointestinal neoplasms; however, most ESD articles report small series, with short-term outcomes performed by multiple operators on single organ. We assessed short- and long-term treatment outcomes following ESD for early neoplasms throughout the gastrointestinal tract.

Methods

We performed a longitudinal cohort study in single tertiary care referral center. A total of 1,635 early gastrointestinal neoplasms (stomach 1,136; esophagus 138; colorectum 361) were treated by ESD by single operator. Outcomes were complication rates, en bloc R0 resection rates, and long-term overall and disease-specific survival rates at 3 and 5 years for both guideline and expanded criteria for ESD.

Results

En bloc R0 resection rates were: stomach: 97.1 %; esophagus: 95.7 %; colorectum: 98.3 %. Postoperative bleeding and perforation rates respectively were: stomach: 3.6 and 1.8 %; esophagus: 0 and 0 %; colorectum: 1.7 and 1.9 %. Intra criteria resection rates were: stomach: 84.9 %; esophagus: 81.2 %; colorectum: 88.6 %. Three-year survival rates for lesions meeting Japanese ESD guideline/expanded criteria were for all organ-combined: 93.4/92.7 %. Five-year rates were: stomach: 88.1/84.6 %; esophagus: 81.6/57.3 %; colorectum: 94.3/100 %. Median follow-up period was 53.4 (range, 0.07–98.6) months. Follow-up rate was 94 % (1,020/1,085). There was no recurrence or disease-related death.

Conclusions

In this large series by single operator, ESD was associated with high curative resection rates and low complication rates across the gastrointestinal tract. Disease-specific and overall long-term prognosis for patients with lesions within intra criteria after curative resection appeared to be excellent.     

Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a single-center experience

Background

In Korea, endoscopic submucosal dissection (ESD) has been widely accepted for the treatment of early gastric cancers (EGCs). However, the understanding of the long-term clinical outcome of ESD for EGC remains insufficient. Therefore, the aim of the present study was to assess the long-term clinical outcome and efficacy of ESD for the treatment of EGCs, including the clinical application of the expanded criteria for ESD.

Methods

From January 2006 to December 2010, a total of 515 patients with 522 EGCs were treated by ESD in our hospital; study enrollment was based on the expanded criteria. Comparisons of resectability (en bloc or piecemeal resection), curability (curative or non-curative), and complications (bleeding and perforation) between the standard and expanded groups were assessed. Thereafter, 336 patients with 342 EGCs were finally included in a long-term analysis of local tumor recurrence, development of synchronous and metachronous cancers, and overall and disease-specific survival rates.

Results

En bloc and curative resection rates of 96.7 % and 88.3 %, respectively, were achieved. The curative resection rate was significantly lower in the expanded group than in the standard group (82.1 % vs. 91.5 %, p = 0.001). During a median follow-up of 24 months, the local tumor recurrence rate was also higher in the expanded group than in the standard group (7.0 % vs. 1.8 %, p = 0.025). Local recurrence was more frequent in lesions with non-curative resection than in those with curative resection (20.0 % vs. 1.3 %, p < 0.001). The 5-year overall and disease-specific survival rates were 88 % and 100 %, respectively; the difference between the standard and expanded groups was not significant (p = 0.834).

Conclusions

ESD appears to be a feasible and effective method for treating EGCs, based on the standard and expanded criteria. Close follow-up surveillance, after ESD, should be standard for all patients.     

Endoscopic submucosal dissection for rectal carcinoid tumors

Background

Endoscopic submucosal dissection (ESD) has an advantage over endoscopic mucosa resection (EMR) by enabling removal of gastrointestinal neoplasms en bloc. The ESD procedure is the treatment of choice for rectal carcinoids that have classic histologic architecture with minimal cellular pleomorphism and sparse mitoses, but it has not been applied for such tumors.

Methods

The ESD procedure was performed for patients with colorectal tumors that fulfilled the inclusion criteria specifying tumor with a diameter of 10 mm or less, no muscular layer invasion, and no metastases to the lymph nodes or distal organs. The ESD procedure was performed for patients with rectal carcinoids but no node or distal metastasis.

Results

This study enrolled 20 rectal carcinoid tumors from 20 consecutive patients. The mean tumor size was 7.6 mm (range, 3–16 mm). En bloc removal was achieved for all the tumors, and the complete resection (en bloc with tumor-free lateral/basal margins) rate was 90% (18/20). The two cases in which the margins were not evaluable due to burn effects still are free of recurrence and metastasis at this writing. Perforation was seen in one case, which was managed nonsurgically.

Conclusions

Precise histolopathogic assessment of the specimens resected en bloc by ESD may reduce tumor recurrence and metastasis after ESD. As the treatment of choice for small rectal carcinoids, ESD is associated with nominal risks of metastatic disease.     

Endoscopic submucosal dissection for laterally spreading tumours of the colorectum in 200 consecutive cases

Background

Colorectal laterally spreading tumours (LSTs) are classified into granular (LST-G) and non-granular (LST-NG) type; each type was sub-grouped into LST-G-H (homogenous) and LST-G-M (nodular mixed) type or LST-NG-F (flat elevated) and LST-NG-FD (pseudodepressed) type, respectively. We assessed the clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection (ESD) for colorectal LSTs, and conducted follow-up after ESD.

Methods

ESD was performed in 196 patients with 204 LSTs that fulfilled the inclusion criteria for colorectal neoplasms. Clinical outcomes including resectability and curability of ESD and perforation were investigated, and factors related to the outcomes were analysed using logistic regression. One hundred thirty-eight patients received endoscopic follow-up for more than 12 months and metastatic surveys in 79 cases of cancerous LSTs.

Results

The incidence of submucosal cancer was lower in LST-G type. There were no significant differences in outcomes regarding LST macroscopic types. Overall en bloc, complete and curative resection, and perforation rates were 86.8%, 77.5%, 82.8% and 9.8%, respectively. Logistic regression analysis showed higher risk of non-curative resection in LST-G-M than in LST-G-H type. No other factors were associated with outcomes. During median follow-up of 35.5 months, no locally recurrent or metastatic tumours were observed, and overall survival was still 100%.

Conclusions

ESD provides acceptable resectability for colorectal LSTs by facilitating en bloc resection, irrespective of macroscopic types. The relatively long-term outcomes may be excellent, but further evaluation is needed for appropriate treatment strategy for each type of LST.     

Clinical validity of the expanded criteria for endoscopic resection of undifferentiated-type early gastric cancer based on long-term outcomes

Background

According to the Japanese Gastric Cancer Treatment Guidelines, the expanded criteria for endoscopic resection (ER) of undifferentiated-type early gastric cancer (UEGC) is ulcer-negative, intramucosal cancer 20 mm or less in diameter without lymphovascular invasion. The aim of this study was to confirm validity of the expanded criteria for curative ER of UEGC.

Methods

Subjects were 125 patients from whom 125 UEGCs were resected endoscopically between April 1990 and March 2011. Endoscopic mucosal resection (EMR) (28 lesions, 28 patients) or endoscopic submucosal dissection (ESD) (97 lesions, 97 patients) was performed. We determined the complete resection rate, post-ER bleeding rate, perforation rate, and outcome in both groups, and analyzed the survival outcomes of 84 patients who were followed for more than 5 years (mean, 101.9 months) according to the indication for ER [expanded criteria for curative (n = 52) vs. criteria for noncurative (n = 32)].

Results

Complete resection rates for EMR and ESD were 54 % (15 of 28) and 89 % (86 of 97), respectively, with that for ESD being significantly higher (p < 0.01). Outcomes after ER were as follows: among 52 cases of UEGC meeting the expanded criteria, additional surgical resection was performed in 11 cases of incomplete resection. No local recurrence or lymph node metastasis was observed. Forty-eight patients who were simply surveyed clinically (93.6 ± 38.4 months) after ER survived without recurrence; the remaining 7 patients died of other causes. Among the 32 cases of UEGC meeting the criteria for noncurative resection, additional surgical resection was performed in 13 cases. Among the 19 follow-up cases (108.3 ± 38.7 months), death due to metastasis of the primary disease occurred in 3 cases, death from other causes occurred in 5 cases, and local residual submucosal recurrence occurred in 1 case.

Conclusions

ESD is a useful technique for complete resection as a total excisional biopsy compared with EMR and radical cure of UEGCs meeting the expanded criteria.     

Endoscopic submucosal dissection for early gastric cancer with undifferentiated histology: could we extend the criteria beyond?

Background

Endoscopic submucosal desection (ESD) is an effective treatment for selected patients with early gastric cancer (EGC). The purpose of this study was to examine the short-term and long-term outcomes of ESD of undifferentiated early gastric cancer.

Methods

Data for 1,241 patients who underwent ESD for treatment of EGC between February 2003 and May 2010 were collected. We performed a retrospective analysis of the medical records of 74 patients diagnosed with undifferentiated EGC. We divided the enrolled cases into two groups: the expanded-criteria group (EC group) versus the non-EC group, according to lesion size, presence of ulceration, and pathologic review.

Results

Of a total of 74 lesions with undifferentiated EGC, as a result of pathologic examination the EC group included 29 cases and the non-EC group included 45 cases. The mean diameter of lesions was 19.86 ± 12.5 mm. The overall rates of en bloc resection and complete resection were 90.5 % (67/74) and 73 % (54/74), respectively. The curative resection rate was low at 31.1 %. If limited to the pathologically diagnosed EC group, the curative resection rate was 79.3 % (23/29). During median follow-up periods of 34 months (range 7–81), local recurrences were observed in 5.5 % (4/74) of patients. All of these were in the non-EC group and all underwent noncurative resection. There was no mortality related to ESD for treatment of EGC during follow-up.

Conclusions

ESD may be a feasible treatment for selected patients with undifferentiated EGC; this should be validated by development of new criteria for ESD for treatment of EGC.     

Factors affecting the technical difficulty and clinical outcome of endoscopic submucosal dissection for colorectal tumors

Background

Endoscopic submucosal dissection (ESD) for colorectal tumors is technically difficult due to the anatomy of the large intestine, with its narrow lumen, thin walls, and redundancy. Here, we assessed factors associated with incomplete resection and difficult colorectal ESD.

Methods

Between November 2009 and April 2013, we performed ESD on 151 consecutive colorectal tumors in 147 patients. We evaluated the clinical outcomes of all cases and conducted multiple logistic regression analysis of the following factors related to incomplete resection and difficult procedure: age, gender, location (right colon, left colon or rectum), tumor size (diameter ≥40 or <40 mm), operation time, morphology [granular-type laterally spreading tumor (LST-G), non-granular-type laterally spreading tumor (LST-NG), or protruded type], fibrosis, and paradoxical movement during the procedure. A procedure that required more than 120 min was defined as a difficult colorectal ESD.

Results

Average tumor size was 32.1 ± 10.7 mm, and the average procedure length was 71.8 ± 49.5 min. The rate of en bloc resection was 94.7 %, while that of en bloc curative resection was 86.8 %. Perforation occurred in 1.3 % of the ESD procedures. Multivariate logistic regression analysis revealed that only severe fibrosis [odds ratio (OR) 4.51; 95 % confidence interval (CI) 1.36–14.91, p = 0.014] contributed to incomplete resection and that a tumor size exceeding 40 mm (OR 5.73 [95 % CI 1.66–19.74], p = 0.006), severe fibrosis (OR 23.31 [95 % CI 6.59–82.54], p < 0.001), and paradoxical movement (OR 4.26 [95 % CI 1.11–16.44], p = 0.035) were independent factors exacerbating the difficulty of colorectal ESD.

Conclusions

Severe fibrosis contributed to both incomplete resection and difficult colorectal ESD. Larger tumor size and paradoxical movement during the procedure were independent factors contributing to the difficulty of colorectal ESD. These factors might enable endoscopists to develop strategies for treating colorectal ESD.     

Endoscopic resection as the first-line treatment for early colorectal cancer: comparison with surgery

Introduction

Endoscopic resection has emerged as an alternative therapeutic option for selected cases of early colorectal cancer. However, even now, few data are available on the comparative effectiveness of endoscopic versus surgical resection of early colorectal cancer. The aim of our study was to compare the clinical outcomes in patients with early colorectal cancer who underwent endoscopic resection and those who underwent surgical resection.

Methods

292 early colorectal cancer lesions in 287 patients who were treated with either endoscopic resection or colorectal surgery (open or laparoscopic colorectal resection) between January 2005 and December 2010 were retrospectively analyzed. After excluding 54 deep submucosal lesions [and/or tumor budding (Grade 2 or 3)], a total of 168 lesions with mucosal/superficial submucosal invasion were treated by endoscopic resection, and 70 lesions with mucosal/superficial submucosal invasion were treated by colorectal surgery.

Results

In the endoscopic resection group, the en bloc resection rate and the complete resection rate were 91.1 and 91.1 %, respectively. In the colorectal surgery group, both the en bloc resection rate and the curative resection rate were 100 %. However, using Log rank test in Kaplan–Meier curve, no significant difference in recurrence rate (including metachronous cancer) during the median follow-up period of 37 months (range, 6–98 months) was observed between the two groups (p = 0.647). In addition, a similar morbidity rate was observed for endoscopic resection compared with surgery (5.4 vs. 5.7 %, p = 0.760). A significantly shorter hospital stay was observed in the endoscopic resection group than colorectal surgery group [median 2 days (range, 2–29) vs. median 10 days (range, 7–37), p < 0.001).

Conclusion

We suggest that endoscopic resection, being equally effective but less invasive than surgery, can be the first-line treatment for well selected early colorectal cancer.     

Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection

Background and Aims

Endoscopic submucosal dissection (ESD) has recently been applied to the treatment of superficial colorectal cancer. Clinical outcomes compared with conventional endoscopic mucosal resection (EMR) have not been determined so our aim was to compare the effectiveness of ESD with conventional EMR for colorectal tumors ≥20 mm.

Methods

This was a retrospective case-controlled study performed at the National Cancer Center Hospital in Tokyo, Japan involving 373 colorectal tumors ≥20 mm determined histologically to be curative resections. Data acquisition was from a prospectively completed database. We evaluated histology, tumor size, procedure time, en bloc resection rate, recurrence rate, and associated complications for both the ESD and EMR groups.

Results

A total of 145 colorectal tumors were treated by ESD and another 228 were treated by EMR. ESD was associated with a longer procedure time (108 ± 71 min/29 ± 25 min; p < 0.0001), higher en bloc resection rate (84%/33%; p < 0.0001) and larger resected specimens (37 ± 14 mm/28 ± 8 mm; p = 0.0006), but involved a similar percentage of cancers (69%/66%; p = NS). There were three (2%) recurrences in the ESD group and 33 (14%) in the EMR group requiring additional EMR (p < 0.0001). The perforation rate was 6.2% (9) in the ESD group and 1.3% (3) in the EMR group (p = NS) with delayed bleeding occurring in 1.4% (2) and 3.1% (7) of the procedures (p = NS), respectively, as all complications were effectively treated endoscopically.

Conclusions

Despite its longer procedure time and higher perforation rate, ESD resulted in higher en bloc resection and curative rates compared with EMR and all ESD perforations were successfully managed by conservative endoscopic treatment.     

Factors related to the curability of early gastric cancer with endoscopic submucosal dissection

Background

Endoscopic submucosal dissection (ESD) yields substantially high rates for curative resection of early gastric cancer (EGC). It is suggested that larger, ulcerative, or upper EGCs may prevent successful ESD. A detailed analysis of factors associated with the curability of ESD was performed.

Methods

Endoscopic submucosal dissection was performed for patients with EGC that fulfilled the expanded criteria, which specified mucosal cancer without ulcer findings irrespective of tumor size, mucosal cancer with ulcers 3 cm in diameter or smaller, and minute submucosal invasive cancer 3 cm or smaller. Resectability (en bloc or by piecemeal resection), curability (curative or non-curative), and complications were assessed, and logistic regression analysis was used to analyze the related factors.

Results

Ulcerative EGCs showed a significantly higher risk associated with ESD on multivariate analysis. When the risk factors (tumor size, location, and ulcer findings) were combined, the larger EGCs (>30 mm) located in the upper third or ulcerative tumors located in the upper and middle portion of the stomach were at significantly higher risk of non-curative resection. Such lesions also were associated with increased risk of procedure-related perforation.

Conclusions

When risk factors including positive ulcer findings and larger size and upper location of tumors are combined, ESD should be performed more carefully.     

Advantages of endoscopic submucosal dissection with needle-knife over endoscopic mucosal resection for small rectal carcinoid tumors: a retrospective study

Background

Endoscopic submucosal dissection (ESD) is a new, widely accepted method for the treatment of early gastric cancer and was developed to increase the en bloc resection rate. This study aimed to evaluate the efficacy and safety of ESD compared with conventional endoscopic mucosal resection (EMR) for small rectal carcinoid tumors.

Methods

A retrospective study was carried out that included 43 patients with small rectal carcinoid tumors (<10 mm). The cohort comprised two groups: Group A (N = 23) underwent conventional EMR from January 2004 to August 2005, while group B (N = 20) underwent ESD with needle-knife from September 2005 to December 2006. The rate of curative en bloc resection, the procedure time, and the incidence of complications were evaluated.

Results

The en bloc resection rate and the rate of completeness of resection of group B were higher than those of group A (100 vs. 87%, 100 vs. 52.5%, respectively). The average operation time required for resection was significantly longer in group B (28.4 ± 17.2 min) compared with group A (12.3 ± 15.4 min) (p < 0.05). None of the patients had immediate or delayed bleeding during the procedure. Perforation occurred in one case of group B and the patient recovered after several days of conservative treatment. Three patients had local recurrence after EMR, while no patient experienced recurrence after ESD.

Conclusion

ESD, compared with conventional EMR, increased en bloc and histologically complete resection rates and may reduce local recurrence rate for small rectal carcinoid tumors. Increased operation time and complication risks with ESD remain problematic. Further technique and investigation are required to confirm the safety and to assess the long-term prognosis of ESD.     

Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S–O clip

Background

Endoscopic submucosal dissection (ESD) allows en bloc resection of superficial colorectal tumors regardless of size. However, ESD is technically difficult, hazardous, and time consuming. New devices may help overcome these drawbacks. We focused on traction methods and designed a new traction device, the “S–O clip.” Its main advantage is that it allows direct visualization of the cutting line during submucosal dissection. Moreover, it can be used at any location without withdrawing the endoscope. The purpose of this study was to evaluate the efficacy and safety of traction device-assisted ESD for large colorectal tumors using the S–O clip.

Methods

Between August 2010 and December 2011, ESD was performed in 70 patients with a superficial colorectal tumor ≥20 mm in diameter in our department. Patients were randomized into two groups: 27 cases in the S–O clip-assisted ESD group and 23 cases in the conventional ESD group. Included in the analysis were patient’s gender and age, tumor form, size, and location, rate of en bloc resection, procedure time, presence or absence of intraoperative perforation or delayed bleeding, and pathological findings. Subgroup analysis stratified by these factors and multivariate analyses were conducted.

Results

In the S–O clip-assisted ESD group, all 27 tumors were resected en bloc without any complications. Although a micro perforation occurred in one patient in the conventional ESD group, further surgical treatment was not required. None of the other 22 cases in the conventional ESD group experienced complications. The mean procedure time for the S–O clip-assisted ESD group was significantly shorter than for the conventional ESD group (37.4 ± 32.6 vs. 67.1 ± 44.1 min, p = 0.03). No significant between-group differences were found for the other factors.

Conclusion

Our results demonstrated that S–O clip-assisted ESD is safe and fast for en bloc resection of large superficial colorectal tumors.     

Endoscopic submucosal dissection for colorectal tumors—1,000 colorectal ESD cases: one specialized institute’s experiences

Purpose

Endoscopic submucosal dissection (ESD) is a very useful endoscopic technique, making it possible to perform en bloc resection regardless of lesion size. Since the introduction of ESD at our hospital, we have performed 1,000 colorectal ESDs during 56 months. The purpose of this study was to evaluate the clinical outcomes of our colorectal ESD experience and to access the efficacy and safety of colorectal ESD.

Methods

Between October 2006 and August 2011, we performed ESD on 1,000 consecutive colorectal tumors in 966 patients. We evaluated the clinical outcomes of all said cases.

Results

The mean resected tumor size was 24.1 ± 13.3 (3–145) mm. Our overall endoscopic en bloc resection rate was 97.5 % (975/1,000), and our R0 resection rate was 91.2 % (912/1,000) respectively. Our perforation rate was 5.3 % (53/1,000). Of these 53 perforations, 50 cases were treated through conservative management with/without endoscopic clipping, whereas the remaining 3 patients received laparoscopic operation. Pathological examination showed adenocarcinoma in 37.2 % of cases (372/1,000) and neuroendocrine tumors in 11.2 % (112/1,000). We recommended additional radical surgery to 82 patients who had a risk of lymph node metastasis. Follow-up colonoscopies were performed on 722 patients. During the median follow-up period of 13 (1–62) months, there were three recurrences (0.4 %).

Conclusions

ESD is technically difficult, with a substantial risk of perforation. However, ESD enabled en bloc resection and pathologically complete resection of large colorectal epithelial tumors and submucosal tumors. As experience with the technique increases, ESD may gradually replace piecemeal endoscopic mucosal resection and radical colon resection in the treatment of colorectal tumors.     

Endoscopic submucosal dissection for colorectal neoplasia during the clinical learning curve

Background

The efficacy of colorectal endoscopic submucosal dissection (ESD) has been reported mainly from Japanese referral centers. However, ESD is technically difficult and associated with a higher risk of adverse events than endoscopic mucosal resection, especially for novices performing colorectal ESD with little experience in gastric ESD. The current study evaluated the results of colorectal ESD during the clinical learning curve by retrospectively examining the results of colorectal ESD performed by four endoscopists who had experience with fewer than five cases of gastric ESD.

Methods

The study retrospectively investigated the first 20 cases managed by each endoscopist, for a total of 80 cases. The main outcome measurements were procedural time, en bloc resection rate with tumor-free margins (R0 resection rate), and adverse events rate. From among clinicopathologic characteristics, factors that affected main outcome measurements were identified.

Results

Of the 80 cases (56 colonic and 24 rectal lesions; 44 granular laterally spreading tumors (LSTs) and 23 nongranular LSTs, 5 depressed, and 8 protruding), 54 cases (67.5 %) had resection using a standard tip-type knife, and 26 cases (32.5 %) had resection using a small scissors-type knife. The mean tumor diameter was 34.9 ± 14.1 mm, and the mean procedural time was 108.8 ± 53.4 min. The resection in 75 cases (93.8 %) was performed en bloc, and the R0 resection rate was 75 % (60/80). Perforation occurred in six cases (7.5 %) and postoperative hemorrhage in three cases (3.8 %). Multivariate analyses showed that colonic lesions and larger lesions (≥40 mm) were significantly associated with prolonged procedural time (≥90 min). Use of the scissors-type knife was significantly associated with a higher R0 resection rate. Perforation occurred only in colonic lesions.

Conclusions

For novices in colorectal ESD, beginning with rectal and smaller lesions may be advisable. Also, using scissors-type knives may increase the R0 resection rate.     

Impact of cumulative time on the clinical outcomes of endoscopic submucosal dissection in gastric neoplasm

Background

Endoscopic submucosal dissection (ESD) can be technically demanding and requires great attention to detail and prolonged concentration. We assumed that clinical outcomes of ESDs may be affected by cumulative time, and we aimed to compare complete resection rates and adverse events according to cumulative ESD time.

Methods

This study involved 1,328 consecutive patients with 1,461 gastric tumors who underwent ESD from January 2008 to July 2011 in a tertiary-care academic medical center. The main outcome measurements were en bloc resection rate, complete resection rate, bleeding rate and perforation rate.

Results

Patients were divided into three groups according to cumulative time intervals (<2 h vs. 2–4 h vs. ≥4 h). Complete resection rate did not differ among the three groups, but early post-ESD bleeding (EPEB) rate was significantly different among the three groups (2.5 vs. 3.5 % vs. 6.6 %, P = 0.040). In multivariate analysis, cumulative time period was an independent predictor of EPEB (2–4 h odds ratio [OR] 2.29, 95 % confidence interval [CI] 1.05–5.01, P = 0.038; ≥4 h OR 3.99; 95 % CI, 2.15–7.65, P < 0.001). The rate of perforation was higher in ESDs performed after completing prior endoscopies or outpatient clinic session compared to those performed without prior work (3.8 vs. 1.6 %, P = 0.004). Moreover, prior workload before ESD was an independent predictor of perforation in multivariate analysis (OR 2.77, 95 % CI, 1.37–5.60, P = 0.005).

Conclusions

Our data suggest that cumulative ESD time did not influence en bloc or complete resection rate of ESD, but increased the rate of acute bleeding. Moreover, prior workload before ESDs may increase the risk of perforation.     

Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions

Background

For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive.

Methods

A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis.

Results

This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3–90.6) for the ESD patients versus 98.7 % (95 % CI 97.4–99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4–78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9–90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4–11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2–13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3–5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0–6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9–13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8–3.7 %) for the TEM patients (P < 0.001).

Conclusions

The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.     

Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan

Background

Conventional endoscopic resection (CER) for early colorectal neoplasia (CRN) is widely accepted as a minimally invasive treatment. Endoscopic submucosal dissection (ESD) was developed in Japan to resect larger lesions, but ESD was not covered by the Japanese national health insurance until April 2012. In addition, treatment strategies vary considerably among medical facilities. To evaluate the current situation in Japan regarding endoscopic treatment of CRNs measuring ≥20 mm, we conducted a prospective multicenter study at 18 medium-volume and high-volume specialized facilities in cooperation with the Japan Society for Cancer of the Colon and Rectum (JSCCR).

Methods

The JSCCR conducted a multicenter, observational study of all patients treated by CER and ESD of CRNs measuring ≥20 mm.

Results

From October 2007 to December 2010, CERs and ESDs were performed on 1,845 CRNs (CERs 1,029; ESDs 816). Lesions diagnosed as protruded, flat, and depressed totaled 541, 1224, and 48, respectively. En bloc resection rates and mean procedure times for CER/ESD were 56.9 %/94.5 % (P < 0.01) and 18 ± 23 min/96 ± 69 min, respectively. The average ESD procedure time was 129 ± 83 min in the ≥40-mm group. As lesion size increased, the CER en bloc resection rate decreased significantly (trend P < 0.01), but the ESD en bloc resection rate remained over 93 %. Perforation and delayed bleeding rates of CER/ESD were 0.8 %/1.6 % (P < 0.05) and 2 %/2.2 % (P = 0.3), respectively.

Conclusions

The en bloc resection rate for ESD was significantly higher than for CER, although complication rates were fairly low. Despite a longer procedure time, safety of colorectal ESD has improved in various facilities in Japan. However, ESD for lesions measuring ≥40 mm must be performed by experienced endoscopists due to the longer procedure time.     

Predictive risk factors of perforation in gastric endoscopic submucosal dissection for early gastric cancer: a large, multicenter study

Background

Although endoscopic submucosal dissection (ESD) is standard therapy for early gastric cancer, the complication rate is unsatisfactory, with perforation as the major complication during ESD. There have been several reports regarding the complications of ESD for gastric tumor especially perforation; however, little is known about the predictors for complications in patients undergoing ESD. The purpose of this retrospective study was to determine the risk factors for perforation in patients with early gastric cancer during ESD.

Methods

Between February 2003 and May 2010, we performed ESD for 1,289 lesions in 1,246 patients at six tertiary academic hospitals in Daegu, Kyungpook, Korea. Patient-related variables (age, sex, and underlying disease), endoscopic-related variables (indication of ESD, lesion size, location, type, and mucosal ulceration), procedure-related variables (operation time, complete resection, and invasion of submucosa/vessel/lymph node), and the pathologic diagnosis were evaluated as potential risk factors.

Results

The mean age of the patients was 64 years. The mean size of the endoscopic lesion was 19.4 mm. The overall en bloc resection rate was 93.3 %. Perforation (microperforation and macroperforation) was seen in 35 lesions. The location of the lesion (long axis: body/short axis: greater and lesser curvature) and piecemeal resection were associated with perforation (p = 0.01/0.047 and p = 0.049). Upon multivariate analysis, the location (body vs. antrum) of the lesion (odds ratio (OR) 2.636; 95 % confidence interval (CI) 1.319–5.267; p = 0.006) and piecemeal resection (OR 2.651; 95 % CI 1.056–6.656; p = 0.038) were significant predictive factors for perforation.

Conclusions

The result of this study demonstrated that the location of the lesion (body) and piecemeal resection were related to perforation during ESD.     

Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding

Background

Endoscopic resection (ER) of sporadic duodenal adenomas (SDAs) is an alternative treatment strategy to surgical excision but carries substantial risks of bleeding. Endoscopic submucosal dissection (ESD) of SDAs has a high rate of perforation. This study aimed to examine the outcome for ER of SDAs in two large UK centers, both using a novel hybrid endoscopic mucosal resection (EMR) with ESD.

Methods

Prospective endoscopy databases of ER cases were examined for the period January 2005 to December 2012. Records were analyzed for patient demographics, lesion size and morphology, staging investigations, procedural technique, outcomes, histology, complications, and follow-up assessments.

Results

The study included 34 patients. The mean adenoma size was 25 mm. Of the 34 cases, 21 (62 %) were managed by the traditional snare EMR technique, 12 (35 %) by the hybrid EMR–ESD technique, and 1 by full en bloc ESD. Successful resection was achieved in 33 (97 %) of the 34 cases. En bloc resection and recurrence rates did not differ significantly between the cases treated by EMR and those treated by hybrid EMR–ESD. Three episodes of significant delayed bleeding occurred 1–18 days after the procedure. No perforations or deaths occurred. The risk of delayed bleeding was higher for the lesions 30 mm in diameter or larger than for the lesions smaller than 30 mm (33% vs. 0 %; p = 0.003). The risk of delayed bleeding was not related to the ER technique used (EMR, 9.5 %; ESD/hybrid, 7.7 %; p = 0.855).

Conclusions

Endoscopic resection is an effective treatment for SDAs and can avoid the need for open surgery. This is the first series to report the use of a hybrid EMR–ESD technique for the treatment of SDAs in a Western setting. However, this technique did not confer any major outcome benefits over EMR. The risk of delayed bleeding is substantial, and bleeding may occur up to 18 days after the procedure. The risk of delayed bleeding was increased with lesions larger than 30 mm but was not influenced by the endoscopic technique.     

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions

Background

Large superficial neoplasias of the ileocecal region pose an increased degree of complexity for endoscopic resection. This study aimed to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for large superficial colorectal neoplasias including ileocecal lesions.

Methods

A total of 33 superficial colorectal neoplasias, including eight neoplasias in the ileocecal region, were treated with ESD from December 2005 to April 2009. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated among three groups: ileocecal region, colon, and rectum.

Results

The mean size of all resected neoplasias was 35 ± 15 mm (range, 20–80 mm) and that of all resected specimens was 41 ± 15 mm (range, 23–82 mm). The mean procedural time was 121 ± 90 min (range, 22–420 min). The difference in mean values among the three groups was not significant. The overall rate of en bloc resection was 91% (30/33). Histopathologically, both the lateral and vertical margins in the specimens resected en bloc tested negative (30/30). The rate for en bloc resection in the ileocecal region did not differ significantly from that for the other two groups (p = 0.20 compared with the rate for the colon and p = 0.12 compared with the rate for the rectum). Complications such as perforation and postoperative bleeding did not occur in the ileocecal group. No recurrence was observed in any cases during the mean follow-up period of 20 ± 12 months (range, 4–44 months).

Conclusions

The ESD approach is safe and effective for treating large superficial neoplasias of the ileocecal region such as other colorectal neoplasias.