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Reply to Wagner et al.
We would like to thank Dr. Wagner and colleagues for their letter and for their compliments on the quality of our article “Histological R0 classification after colorectal endoscopic submucosal dissection: a gold standard with feet of clay.”
As reported in the article, the 4-cm granular LST in the left colon indeed had a 10-mm Kudo Vn, Sano 3b demarcated area highly suspicious of deep degeneration.
Our team recently reported that diagnostic ESD is feasible and safe for colorectal lesions with a focal deep invasive pattern of less than 15 mm . The study showed that ESD cured 26.6 % of patients and could be a valid option for 30.6 % (low risk T1 cancers with submucosal invasion > 1000 μm without any other unfavorable criteria), especially for frail patients with comorbidities. Therefore, routine referral of these lesions to surgery may not be adequate.
On the other hand, endoscopic intermuscular dissection (EID) in the rectum has been recently described and could provide vertical free margins, by dissecting more deeply between the two muscle layers, when the deep submucosa is invaded .
As no endoscopic criteria can predict lymphatic invasion, tumor budding, or poor histological differentiation, we believe that ESD could be proposed to obtain an accurate pathological assessment to avoid systematic surgery, with a much safer morbimortality profile .
Article published online:
29 August 2023
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- 2 Masgnaux L-J, Yzet C, Rivory J. et al. Endoscopic intermuscular dissection of rectal T1 cancer with adaptive traction: use of additional loops to improve traction directly on the circular muscular layer. Endoscopy 2023; 55: E410-E411
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