Preoperative endoscopic predictors of severe submucosal fibrosis in colorectal tumors undergoing endoscopic submucosal dissection

Abstract

Background and study aims Endoscopic submucosal dissection (ESD) enables en bloc removal of colorectal neoplasms regardless of size. Submucosal fibrosis is a significant factor for technical difficulty and poor outcomes. We assessed the predictive factors for severe submucosal fibrosis and the ESD outcomes.

Patients and methods Patients undergoing ESD from January 2006 to September 2017 were retrospectively reviewed. The degree of submucosal fibrosis was classified into three types: no fibrosis (F0), mild fibrosis (F1), and severe fibrosis (F2). F0 and F1 cases were grouped as non-severe fibrosis for comparison with the severe fibrosis group. Predictors of severe submucosal fibrosis and ESD outcomes were evaluated.

Results ESD was performed in 524 lesions (60 % male; mean age, 67.8 years). Eighty lesions with severe fibrosis (15.3 %) were observed. The overall en bloc resection rate and curative resection rate were 94.3 % and 77.7 %, respectively. Rates of en bloc resection (91.2 % vs. 94.8 %, P = 0.2) and perforation (7.5 % vs. 5.6 %, P = 0.45) were no different between severe fibrosis and non-severe fibrosis groups. However, incidences of non-curative resection and low resection speed were significantly higher in the severe fibrosis group. Among protruding lesions, tumor height and volume were significantly greater in the severe counterparts. A diameter ≥ 40 mm, endoscopic finding of the tumor beyond fold, and fold convergence were independent risk factors for severe fibrosis.

Conclusions Severe submucosal fibrosis is a significant risk factor for non-curative resection and a long procedural time. Tumor size and morphology might help to predict the severity of fibrosis.

• References

• 1 Wang J, Zhang XH, Ge J. et al. Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal tumors: a meta-analysis. World J Gastroenterol 2014; 20: 8282-8287
• 2 Sato K, Ito S, Kitagawa T. et al. Factors affecting the technical difficulty and clinical outcome of endoscopic submucosal dissection for colorectal tumors. Surg Endosc 2014; 28: 2959-2965
• 3 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
• 4 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
• 5 He Y, Wang X, Du Y. et al. Predictive factors for technically difficult endoscopic submucosal dissection in large colorectal tumors. Turk J Gastroenterol 2016; 27: 541-546
• 6 Kim EK, Han DS, Ro Y. et al. The submucosal fibrosis: what does it mean for colorectal endoscopic submucosal dissection?. Intest Res 2016; 14: 358-364
• 7 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
• 8 Hori K, Uraoka T, Harada K. et al. Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum. Endoscopy 2014; 46: 862-870
• 9 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
• 10 Inada Y, Yoshida N, Kugai M. et al. Prediction and treatment of difficult cases in colorectal endoscopic submucosal dissection. Gastroenterol Res Pract 2013; 2013: 523084
• 11 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
• 12 Ozawa S, Tanaka S, Hayashi N. et al. Risk factors for vertical incomplete resection in endoscopic submucosal dissection as total excisional biopsy for submucosal invasive colorectal carcinoma. Int J Colorectal Dis 2013; 28: 1247-1256
• 13 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
• 14 Ikehara H, Saito Y, Matsuda T. et al. Diagnosis of depth of invasion for early colorectal cancer using magnifying colonoscopy. J Gastroenterol Hepatol 2010; 25: 905-912
• 15 Backes Y, Moss A, Reitsma JB. et al. Narrow band imaging, magnifying chromoendoscopy, and gross morphological features for the optical diagnosis of T1 colorectal cancer and deep submucosal invasion: a systematic review and meta-analysis. Am J Gastroenterol 2017; 112: 54-64
• 16 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
• 17 Lee SP, Kim JH, Sung IK. et al. Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: pathologic review of 173 cases. J Gastroenterol Hepatol 2015; 30: 872-878
• 18 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
• 19 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434
• 20 Toyonaga T, Man IM, Morita Y. et al. Endoscopic submucosal dissection (ESD) versus simplified/hybrid ESD. Gastrointest Endosc Clin N Am 2014; 24: 191-199
• 21 Watanabe T, Itabashi M, Shimada Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol 2015; 20: 207-239
• 22 Kudo S, Lambert R, Allen JI. et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc 2008; 68: S3-S47
• 23 Yamashina T, Takeuchi Y, Uedo N. et al. Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm. J Gastroenterol Hepatol 2016; 31: 615-620
• 24 Bosman FT. World Health O. WHO classification of tumours of the digestive system. Lyon, France: IARC Press; 2010: 134-146
• 25 Rockey DC, Bell PD, Hill JA. Fibrosis--a common pathway to organ injury and failure. N Engl J Med 2015; 372: 1138-1149
• 26 Gordon IO, Agrawal N, Willis E. et al. Fibrosis in ulcerative colitis is directly linked to severity and chronicity of mucosal inflammation. Aliment Pharmacol Ther 2018; 47: 922-939
• 27 Chiba H, Tachikawa J, Kurihara D. et al. Successful endoscopic submucosal dissection of colon cancer with severe fibrosis after tattooing. Clin J Gastroenterol 2017; 10: 426-430
• 28 Fu K, Sano Y, Kato S. et al. Hazards of endoscopic biopsy for flat adenoma before endoscopic mucosal resection. Dig Dis Sci 2005; 5: 1324-1327
• 29 Han KS, Sohn DK, Choi DH. et al. Prolongation of the period between biopsy and EMR can influence the nonlifting sign in endoscopically resectable colorectal cancers. Gastrointest Endosc 2008; 67: 97-102
• 30 Horii J, Uraoka T, Goto O. et al. Endoscopic submucosal dissection of colorectal neoplasia located on the suture line of anastomosis. Clin J Gastroenterol 2014; 7: 290-294
• 31 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
• 32 Hayashi Y, Shinozaki S, Sunada K. et al. Efficacy and safety of endoscopic submucosal dissection for superficial colorectal tumors more than 50 mm in diameter. Gastrointest Endosc 2016; 83: 602-607
• 33 Imai K, Hotta K, Yamaguchi Y. et al. Endoscopic submucosal dissection for large colorectal neoplasms. Dig Endosc 2017; 29: 53-57
• 34 Hirata I, Wang FY, Murano M. et al. Histopathological and genetic differences between polypoid and non-polypoid submucosal colorectal carcinoma. World J Gastroenterol 2007; 13: 2048-2052
• 35 Saito S, Tajiri H, Ikegami M. Endoscopic features of submucosal deeply invasive colorectal cancer with NBI characteristics: S Saito et al. Endoscopic images of early colorectal cancer. Clin J Gastroenterol 2015; 8: 353-359
• 36 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
• 37 Boda K, Oka S, Tanaka S. et al. Clinical outcomes of endoscopic submucosal dissection for colorectal tumors: a large multicenter retrospective study from the Hiroshima GI Endoscopy Research Group. Gastrointest Endosc 2018; 87: 714-722
• 38 Jeong JY, Oh YH, Yu YH. et al. Does submucosal fibrosis affect the results of endoscopic submucosal dissection of early gastric tumors?. Gastrointest Endosc 2012; 76: 59-66