Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum

Background and study aims: Laterally spreading tumors – non granular type (LST-NG) are more often considered candidates for endoscopic submucosal dissection (ESD) than laterally spreading tumors – granular type (LST-G), because of their higher potential for submucosal invasion. However, ESD for LST-NG can be technically difficult. The aim of our study was to compare our ESD results for LST-NG and for LST-G.

Patients and methods: Ninety-nine LST-NG and 169 LST-G measuring 20 mm in size or more were removed by ESD. We retrospectively evaluated the clinicopathological features of the tumors and treatment results (en bloc resection rate, procedure time and speed, rate of use of ancillary devices, and complication and recurrence rates).

Results: Histopathology revealed that there were more submucosally invasive lesions in the LST-NG than in the LST-G group (28 % vs. 9 %; P < 0.0001). The en bloc resection rate, en bloc R0 resection rate, and en bloc curative resection rate of LST-NG were similar to those of LST-G (LST-NG: 99 %, 98 %, and 88 %; LST-G: 99 %, 98 %, and 91 %). In LST-NG, the median procedure time tended to be longer (LST-NG: 69 min; LST-G: 60 min) and the median procedure speed was slower (LST-NG: 0.15 cm²/min; LST-G: 0.25 cm²/min; P < 0.0001). Use of ancillary devices was higher for LST-NG (38 % vs. 15 % for LST-G; P < 0.0001), as was the perforation rate (5.1 % vs. 0.6 % for LST-G; P = 0.027). No recurrence was seen in either group.

Conclusions: ESD was an effective treatment method for both LST-NG and LST-G. However, the degree of technical difficulty appears higher for LST-NG than for LST-G lesions, as shown by the lower dissection speed and higher perforation rate. ESD for LST-NG should probably be performed by those with significant experience of colorectal ESD.

References

• 1 Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer.  Endoscopy. 1993;  25 455-461
• 2 Tanaka S, Haruma K, Oka S. et al . Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm.  Gastrointest Endosc. 2001;  54 62-66
• 3 Tanaka S, Haruma K, Teixeira C R. et al . Endoscopic treatment of submucosal invasive colorectal carcinoma with special reference to risk factors for lymph node metastasis.  J Gastroenterol. 1995;  30 710-717
• 4 Nusko G, Mansmann U, Partzsch U. et al . Invasive carcinoma in colorectal adenomas: multivariate analysis of patient and adenoma characteristics.  Endoscopy. 1997;  29 626-31
• 5 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002.  Gastrointest Endosc. 2003;  58 S3-S43
• 6 Kitajima K, Fujimori T, Fujii S. et al . Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study.  J Gastroenterol. 2004;  39 534-543
• 7 Saito Y, Fujii T, Kondo H. et al . Endoscopic treatment for laterally spreading tumors in the colon.  Endoscopy. 2001;  33 682-686
• 8 Tamura S, Nakajo K, Yokoyama Y. et al . Evaluation of endoscopic mucosal resection for laterally spreading rectal tumors.  Endoscopy. 2004;  36 306-312
• 9 Hurlstone D P, Sanders D S, Cross S S. et al . Colonoscopic resection of lateral spreading tumors: a prospective analysis of endoscopic mucosal resection.  Gut. 2004;  53 1334-1339
• 10 Uraoka T, Saito Y, Matsuda T. et al . Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum.  Gut. 2006;  55 1592-1597
• 11 Yamamoto H, Sunada K, Miyata T. et al . Endoscopic submucosal dissection using sodium hyaluronate for large superficial tumors in the colon.  Dig Endosc. 2004;  16 178-181
• 12 Onozato Y, Kakizaki S, Ishihara H. et al . Endoscopic submucosal dissection for rectal tumors.  Endoscopy. 2007;  39 423-427
• 13 Toyonaga T, Nishino E, Hirooka T. et al . Endoscopic submucosal dissection for the large intestine and selection of treatment apparatus. [in Japanese with English abstract].  Endoscopia Digestiva. 2004;  16 1473-1480
• 14 Toyonaga T. ESD atlas. 1st edn. [in Japanese]. Tokyo; Kanehara 2006
• 15 Toyonaga T, Man-I M, Ivanov D. et al . The results and limitations of endoscopic submucosal dissection for colorectal tumors.  Acta Chir Iugosl. 2008;  55 17-23
• 16 Toyonaga T, Inokuchi H, Man-I M. et al . Endoscopic submucosal dissection using water jet short needle knives (Flush knife) for the treatment of gastrointestinal epithelial neoplasms.  Acta Endoscopica. 2007;  37 645-656
• 17 Tanaka S, Oka S, Kaneko I. et al . Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization.  Gastrointest Endosc. 2007;  66 100-107
• 18 Kodashima S, Fujishiro M, Yahagi N. et al . Endoscopic submucosal dissection using Flex knife.  J Clin Gastroenterol. 2006;  40 378-384
• 19 Toyonaga T, Nishino E, Hirooka T. Invention of water jet short needle knives (Flush knife) for endoscopic submucosal dissection [in Japanese with English abstract].  Endoscopia Digestiva. 2005;  17 2167-2174
• 20 Oyama T, Kikuchi Y. Aggressive endoscopic mucosal dissection in the upper GI tract: Hook knife EMR method.  Min Invas Ther Allied Technol. 2002;  11 291-295
• 21 Toyonaga T, Nishino E, Hirooka T. et al . Use of short needle knife for esophageal endoscopic submucosal dissection.  Dig Endosc. 2005;  17 246-252
• 22 Toyonaga T, Nishino E, Hirooka T. et al . Invention of water jet short needle knives for endoscopic submucosal dissection.  Endoscopy. 2005;  37 A19
• 23 Yahagi N, Fujishiro M, Omata M. Endoscopic submucosal dissection of colorectal lesion.  Dig Endosc. 2004;  16 S178-S181
• 24 Fujishiro M, Yahagi N, Kakushima N. et al . Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases.  Clin Gastroenterol Hepatol. 2007;  5 678-683
• 25 Saito Y, Uraoka T, Matsuda T. et al . Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections.  Gastrointest Endosc. 2007;  66 966-973
• 26 Tamegai Y, Saito Y, Masaki N. et al . Endoscopic submucosal dissection: a safe technique for colorectal tumors.  Endoscopy. 2007;  39 418-422
• 27 Elm E von, Altman D G, Egger M. et al; STROBE Initiative . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.  Ann Intern Med. 2007;  147 573-577
• 28 Yamamoto H, Yube T, Isoda N. et al . A novel method of endoscopic mucosal resection using sodium hyaluronate.  Gastrointest Endosc. 1999;  50 251-256
• 29 Gotoda T, Kondo H, Ono H. et al . A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases.  Gastrointest Endosc. 1999;  50 560-563
• 30 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 31 Yahagi N, Fujishiro M, Kakushima N. et al . Endoscopic submucosal dissection for early gastric cancer using the tip of an electro surgical snare (thin type).  Dig Endosc. 2004;  16 34-38
• 32 Fujishiro M, Yahagi N, Nakamura M. et al . Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar.  Gastrointest Endosc. 2006;  63 243-249
• 33 Saito Y, Emura F, Matsuda T. et al . A new sinker-assisted endoscopic submucosal dissection for colorectal cancer.  Gastrointest Endosc. 2005;  62 297-301
• 34 Yamamoto H, Yahagi N, Oyama T. Mucosectomy in the colon with endoscopic submucosal dissection.  Endoscopy. 2005;  37 764-768
• 35 Soetikno R M, Gotoda T, Nakanishi Y. et al . Endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 567-579
• 36 Binmoeller K F, Bohnacker S, Seifert H. et al . Endoscopic snare excision of “giant” colorectal polyp.  Gastrointest Endosc. 1996;  43 183-188
• 37 Walsh R M, Ackroyd F W, Shellito P C. Endoscopic resection of large sessile colorectal polyps.  Gastrointest Endosc. 1992;  38 303-309
• 38 Kudo S, Tamura S, Nakajima T. et al . Diagnosis of colorectal tumorous lesions by magnifying endoscopy.  Gastrointest Endosc. 1996;  44 8-14
• 39 Netzer P, Forster C, Biral R. et al . Risk factor assessment of endoscopically removed injection for EMR.  Gastrointest Endosc. 2005;  3 S74-S76
• 40 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
• 41 Takeuchi Y, Uedo N, Ishihara R. et al . Efficacy of an endo-knife with a water-jet function (Flushknife) for endoscopic submucosal dissection of superficial colorectal neoplasms.  Am J Gastroenterol. 2010;  105 314-322