ESD for proximal colonic lesions: a safe and effective therapeutic option

Aims Endoscopic submucosal dissection (ESD) is the standard of treatment for rectal lesions due to the high risk of submucosal invasion. On the other hand, for proximal lesions is not widely adopted due to the very low risk of submucosal invasion and the technical challenges of the approach. Aim of our study was to assess technical and clinical outcome of patients treated by ESD for lesions located proximally to the splenic flexure.

Methods All consecutive ESD and Hybrid ESD from 2012 to 2023 for lesions proximal to splenic flexure were extracted from our prospectively maintained registry of colorectal ESD. Primary outcome was the completeness of resection based on en bloc and R0 resection rates. The secondary outcomes were histology, complications and hospital stay. For patients who underwent surgery after endoscopic resection the residual disease on the histologic specimen was also evaluated.

Results The sample was composed of 116 endoscopic dissections (57 conventional and 59 Hybrid ESD) performed in the proximal colon (19.82% cecum, 1.72% ileocecal valve, 43.96% ascending colon, 17.24% right flexure, 17.24% transverse). The primary outcome was achieved in 94.73% of classic ESD and 71.18% of hybrid-ESD with en-bloc resection in 96/116 patients (82.76%). Intraprocedural complications reported were bleeding (3.45%) and perforation (9.48%). Delayed complications observed were PECS (4.31%) and bleeding (1.72%). The median hospital stay was 1.63±1.09 days; no perforations occurred. The histologic analysis showed that 25.21% of samples were adenocarcinoma (G1-G2 86.66%), 40.0% low grade dysplasia and 33.91% high grade dysplasia. Lateral and deep margins were involved by dysplasia in 14.29% and 7.08% of samples, respectively. Features associated with high risk of lymph nodes dissemination, like vascular invasion and depth sm2-sm3 were 6.67% and 40.74%, respectively. Further surgery for oncological reasons was performed in 9.4% patients (11/116) and only 1 patient presented residual disease on the surgical sample; in this patient the procedure was considered unsuccessful due to non-en-bloc dissection. No positive lymph nodes were found in any surgical patient. In multivariate analysis only the size of the lesion correlates with the completeness of resection (R0 if size<40 mm, OR 0.45 [0.22-0.83], p=0.03). Data of 3-year follow up were available for 21 patients and only one presented delayed recurrence. Data of 1-year follow-up were available for 38 patients and 4 of them presented recurrence (2 had deep margins involvement and 3 over 4 had high-grade dysplasia).

Conclusions ESD and hybrid ESD is feasible for high-risk for proximal colonic lesions and allow the achievement of high rate of complete resection, mostly en-bloc, with acceptable balance between advantage and complications. Data from surgery samples and follow-up suggest the possible value as a curative technique also in patients with high-risk histological features.

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Artikel online veröffentlicht:
15. April 2024