Endoscopic mucosal resection of laterally spreading lesions involving the ileocecal valve: technique, risk factors for failure, and outcomes
submitted: 13. Oktober 2014
accepted after revision: 14. Januar 2015
12. März 2015 (online)
Background and study aims: Endoscopic mucosal resection (EMR) of laterally spreading lesions (LSLs) involving the ileocecal valve (ICV) is technically demanding. Conventionally, these lesions are considered too challenging for endoscopic therapy and are primarily managed surgically. The aims of the study were to describe effectiveness, safety, and outcomes following EMR of LSLs at the ICV.
Patients and methods: This was a single-center, prospective, observational, cohort study performed at an academic, tertiary referral center. Patients undergoing EMR for LSLs ≥ 20 mm involving the ICV were recruited over a 5-year period. Standard or cap-assisted colonoscopy with inject-and-resect EMR technique was performed with standardized post-EMR management. Procedural success, safety, and outcomes compared with non-ICV LSLs managed during the same period were analyzed.
Results: A total of 53 patients with ICV LSLs were referred for EMR (median age 69 years; median lesion size 35.0 mm; 52.8 % females). Six patients went directly to surgery because of an endoscopic diagnosis of malignancy (n = 2) or technical failure of EMR (n = 4). EMR achieved complete adenoma clearance in 44 out of 47 attempted (93.6 %). Surgery was ultimately avoided in 43/53 (81.1 %). Complications included bleeding in 6.4 %. There were no perforations or strictures. Early adenoma recurrence was detected in 7/40 patients (17.5 %), and 1/22 (4.5 %) had late recurrence. All were successfully managed endoscopically. Factors associated with failure of ICV EMR were ileal infiltration and involvement of both ICV lips.
Conclusions: In the majority of cases, LSL involving the ICV can be effectively treated by EMR on an outpatient basis. In specialized centers, complications are infrequent, and > 80 % of patients ultimately avoid surgery.
Trial registered at ClinicalTrials.gov (NCT01368289).
- 1 Moss A, Bourke MJ, Williams SJ et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1909-1918
- 2 Swan MP, Bourke MJ, Alexander S et al. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). . Gastrointest Endosc 2009; 70: 1128-1136
- 3 Ahlensteil G, Hourigan L, Brown G et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80: 668-676
- 4 Holt BA, Bassan MS, Sexton A et al. Advanced mucosal neoplasia of the anorectal junction: endoscopic resection technique and outcomes (with videos). Gastrointest Endosc 2014; 79: 119-126
- 5 Conio M, Blanchi S, Filiberti R et al. Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve. Endoscopy 2010; 42: 677-680
- 6 Holt BA, Bourke MJ. Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions. Clin Gastroenterol Hepatol 2012; 10: 969-979
- 7 Buchner AM, Guarner-Argente C, Ginsberg GG. Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center. Gastrointest Endosc 2012; 76: 255-263
- 8 Tolliver KA, Rex DK. Colonoscopic polypectomy. Gastroenterol Clin North Am 2008; 37: 229-251
- 9 Pokala N, Delaney CP, Kiran RP et al. Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection. Surg Endosc 2007; 21: 400-403
- 10 Whitson MJ, Bodian CA, Aisenberg J et al. Is production pressure jeopardizing the quality of colonoscopy? A survey of U.S. endoscopists’ practices and perceptions. . Gastrointest Endosc 2012; 75: 641-648
- 11 Anderson MA, Ben-Menachem T, Gan SI et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
- 12 Nanda KS, Bourke MJ. Endoscopic mucosal resection and complications. Tech Gastroint Endosc 2013; 15: 88-95
- 13 Moss A, Bourke MJ, Metz AJ. A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. Am J Gastroenterol 2010; 105: 2375-2382
- 14 Bassan MS, Holt B, Moss A et al. Carbon dioxide insufflation reduces number of postprocedure admissions after endoscopic resection of large colonic lesions: a prospective cohort study. Gastrointest Endosc 2013; 77: 90-95
- 15 Hildreth DH, Bishop RP, Johnson TR. Adenomatous polyps of the ileocecal valve: report of three cases. Dis Colon Rectum 1975; 18: 52-58
- 16 Tsuchida K, Joh T, Okayama N et al. Ileal adenoma with high-grade dysplasia involving the ileocecal valve treated by endoscopic mucosal resection: a case report. Gastrointest Endosc 2002; 55: 125-128
- 17 Kishimoto G, Saito Y, Takisawa H et al. Endoscopic submucosal dissection for large laterally spreading tumors involving the ileocecal valve and terminal ileum. World J Gastroenterol 2012; 18: 291-294
- 18 Ishii N, Itoh T, Horiki N et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions. Surg Endosc 2010; 24: 1941-1947
- 19 Wilhelm D, von Delius S, Weber L et al. Combined laparoscopic-endoscopic resections of colorectal polyps: 10-year experience and follow-up. Surg Endosc 2009; 23: 688-693
- 20 Benedix F, Kockerling F, Lippert H et al. Laparoscopic resection for endoscopically unresectable colorectal polyps: analysis of 525 patients. Surg Endosc 2008; 22: 2576-2582
- 21 Lee SW, Garrett KA, Shin JH et al. Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps. Dis Colon Rectum 2013; 56: 869-873
- 22 Hofmann AF, Poley JR. Role of bile acid malabsorption in pathogenesis of diarrhea and steatorrhea in patients with ileal resection. I. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. . Gastroenterology 1972; 62: 918-934
- 23 Cosnes J, Gendre JP, Le QuintrecY. Role of the ileocecal valve and site of intestinal resection in malabsorption after extensive small bowel resection. Digestion 1978; 18: 329-336
- 24 Moss A, Williams SJ, Hourigan LF et al. Long term adenoma recurrence following wide field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) Study. Gut 2015; 64: 57-65