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Ortiz O, Daca-Alvarez M, Rivero-Sánchez L, Saez De Gordoa K, Moreira R, Cuatrecasas M, Balaguer F, Pellisé M. Linked-color imaging versus high definition white-light endoscopy for evaluation of post-polypectomy scars of nonpedunculated lesions: LCI-Scar study. Endoscopy 2024; 56:283-290. [PMID: 37931908 DOI: 10.1055/a-2204-3236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Detection and treatment of recurrence after piecemeal endoscopic mucosal resection of nonpedunculated colorectal polyps are crucial for avoidance of post-colonoscopy cancer. Linked-color imaging (LCI) has demonstrated improved polyp detection but has never been assessed for evaluation of post-polypectomy scars. Our aim was to compare sensitivity and negative predictive value (NPV) between LCI and white-light endoscopy (WLE) for detection of post-polypectomy recurrence. METHODS Patients undergoing surveillance colonoscopy after resection of lesions ≥15 mm were included in this prospective, single-center, randomized, crossover study. Each post-polypectomy scar underwent two examinations, one with LCI and the other with WLE, performed by two blinded endoscopists. Blue-light imaging (BLI) was then applied. A diagnosis of recurrence with a level of confidence was made for each modality and histopathology was the gold standard. RESULTS 129 patients with 173 scars were included. Baseline patient, lesion, and procedural characteristics were similar in both arms. Recurrence was detected in 56/173 (32.4%), with 27/56 (48.2%) adenomas and 29/56 (51.8%) serrated lesions. LCI had greater sensitivity (96.4% [95%CI 87.8%-99.5%]) versus WLE (89.3% [95%CI 78.1%-95.9%]) and greater NPV (98.1% [95%CI 93.4%-99.8%] versus 94.6% [95%CI 88.7%-98.0%]). Paired concordance between modalities was 96.0%. In discordant cases, LCI identified four true-positive cases not detected by WLE and reclassified one false-positive of WLE. WLE reclassified two false positives of LCI without any increase in recurrence detection. CONCLUSIONS LCI was highly accurate and had greater ability than WLE to rule out recurrence on post-polypectomy scars after resection of large polyps.
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Affiliation(s)
- Oswaldo Ortiz
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Maria Daca-Alvarez
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Liseth Rivero-Sánchez
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | | | - Rebeca Moreira
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Miriam Cuatrecasas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Pathology, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Francesc Balaguer
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
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Ishikawa T, Okimoto K, Matsumura T, Ogasawara S, Fukuda Y, Kitsukawa Y, Yokoyama Y, Kanayama K, Akizue N, Iino Y, Ohta Y, Ishigami H, Taida T, Tsuchiya S, Saito K, Kamezaki H, Kobayashi A, Kikuchi Y, Tada M, Shiko Y, Ozawa Y, Kato J, Yamaguchi T, Kato N. Risk factors of unintentional piecemeal resection in endoscopic mucosal resection for colorectal polyps ≥ 10 mm. Sci Rep 2024; 14:493. [PMID: 38177176 PMCID: PMC10766986 DOI: 10.1038/s41598-023-50815-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/26/2023] [Indexed: 01/06/2024] Open
Abstract
This study aimed to investigate the lesion and endoscopist factors associated with unintentional endoscopic piecemeal mucosal resection (uniEPMR) of colorectal lesions ≥ 10 mm. uniEPMR was defined from the medical record as anything other than a preoperatively planned EPMR. Factors leading to uniEPMR were identified by retrospective univariate and multivariate analyses of lesions ≥ 10 mm (adenoma including sessile serrated lesion and carcinoma) that were treated with endoscopic mucosal resection (EMR) at three hospitals. Additionally, a questionnaire survey was conducted to determine the number of cases treated by each endoscopist. A learning curve (LC) was created for each lesion size based on the number of experienced cases and the percentage of uniEPMR. Of 2557 lesions, 327 lesions underwent uniEPMR. The recurrence rate of uniEPMR was 2.8%. Multivariate analysis showed that lesion diameter ≥ 30 mm (odds ratio 11.83, 95% confidence interval 6.80-20.60, p < 0.0001) was the most associated risk factor leading to uniEPMR. In the LC analysis, the proportion of uniEPMR decreased for lesion sizes of 10-19 mm until 160 cases. The proportion of uniEPMR decreased with the number of experienced cases in the 20-29 mm range, while there was no correlation between the number of experienced cases and the proportion of uniEPMR ≥ 30 mm. These results suggest that 160 cases seem to be the minimum number of cases needed to be proficient in en bloc EMR. Additionally, while lesion sizes of 10-29 mm are considered suitable for EMR, lesion sizes ≥ 30 mm are not applicable for en bloc EMR from the perspective of both lesion and endoscopist factors.
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Affiliation(s)
- Tsubasa Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan.
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
- Translational Research and Development Center, Chiba University Hospital, Chiba, Japan
| | - Yoshihiro Fukuda
- Department of Gastroenterology, Seikei-kai Chiba Medical Center, Chiba, Japan
| | - Yoshio Kitsukawa
- Department of Gastroenterology, Chiba Municipal Aoba Hospital, Chiba, Japan
| | - Yuya Yokoyama
- Department of Gastroenterology, Chibaken Saiseikai Narashino Hospital, Chiba, Japan
| | - Kengo Kanayama
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Yotaro Iino
- Department of Gastroenterology, Kimitsu Chuo Hospital, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Hideaki Ishigami
- Department of Gastroenterology, Chiba Rosai Hospital, Chiba, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Shin Tsuchiya
- Department of Gastroenterology, Funabashi Central Hospital, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Hidehiro Kamezaki
- Department of Gastroenterology, Eastern Chiba Medical Center, Chiba, Japan
| | - Akitoshi Kobayashi
- Department of Gastroenterology, Funabashi Municipal Medical Center, Chiba, Japan
| | - Yasuharu Kikuchi
- Department of Gastroenterology, Numazu City Hospital, Shizuoka, Japan
| | - Minoru Tada
- Department of Gastroenterology, National Hospital Organization Chiba Medical Center, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshihito Ozawa
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
| | - Taketo Yamaguchi
- Department of Gastroenterology, Funabashi Central Hospital, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chuo-ku, Chiba-City, 260-8670, Japan
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Jacques J, Neuhaus H, Enderle MD, Biber U, Linzenbold W, Schenk M, Khalaf K, Repici A. Colorectal Endoscopic Submucosal Dissection: Performance of a Novel Hybrid-Technology Knife in an Animal Trial. Diagnostics (Basel) 2023; 13:3347. [PMID: 37958243 PMCID: PMC10650536 DOI: 10.3390/diagnostics13213347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) was developed for the removal of benign and early malignant lesions in the gastrointestinal tract. We aimed to evaluate the performance and safety of a novel high-pressure waterjet-assisted ESD knife in colorectal applications. Six female German Landrace pigs with an average weight of 62 kg (range 60-65 kg) were used in this prospective, randomized, and controlled study. Twenty-four ESDs were performed by three endoscopists: Twelve each with the new Erbe HYBRIDknife® flex T-Type (HK-T) and the Olympus DualKnife® J (DK-J), including six rectal and six colonic ESDs per instrument. The order of performance was randomized regarding anatomic position and instrument. As the primary endpoint, ESD knife performance characteristics were combined and rated on a 5-point Likert scale, with 5 Likert points (LP) representing the best response (5 = very good). The HK-T was rated significantly better than the DK-J (4.7 LP versus 4.4 LP, p = 0.0295), mainly because of HK-T injection ability (5 LP versus 3 LP, p < 0.0001) and hemostasis (5 LP versus 4 LP, p = 0.0452). There was no difference in procedure time (HK-T: 35 min versus DK-J: 34 min, p = 0.8005), resection diameter (3.1 cm versus 2.8 cm, p = 0.3492), injection volume (41 mL versus 46 mL, p = 0.5633), and complication rates. HK-T is as effective as DK-J in colorectal ESD in terms of dissection quality but has better injection and hemostatic properties. The impact of these technical advantages on the ESD treatment of patients with large superficial colorectal lesions remains to be clinically verified.
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Affiliation(s)
- Jérémie Jacques
- Department of Hepato-Gastro-Enterology, University Hospital Center, 87042 Limoges, France
| | - Horst Neuhaus
- Medical Clinic for Gastroenterology at the Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | | | - Ulrich Biber
- Erbe Elektromedizin GmbH, 72072 Tuebingen, Germany
| | | | - Martin Schenk
- Department of Experimental Medicine, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Kareem Khalaf
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, 20089 Milan, Italy
- Department of Biomedical Science, Humanitas University, 20072 Milan, Italy
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, 20089 Milan, Italy
- Department of Biomedical Science, Humanitas University, 20072 Milan, Italy
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Tate DJ, Desomer L, Argenziano ME, Mahajan N, Sidhu M, Vosko S, Shahidi N, Lee E, Williams SJ, Burgess NG, Bourke MJ. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72:1875-1886. [PMID: 37414440 DOI: 10.1136/gutjnl-2023-330300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort. DESIGN Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two. RESULTS 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up. CONCLUSIONS RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases. TRIAL REGISTRATION NUMBERS NCT01368289 and NCT02000141.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Maria Eva Argenziano
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
| | - Neha Mahajan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Haasnoot KJC, Baldaque-Silva F, Koch A, Figueiredo Ferreira M, Santos-Antunes J, Dias E, Omae M, van Tilburg L, Dang H, Lemmers A, Boonstra JJ, Moons LMG. Low risk of local recurrence after a successful en bloc endoscopic submucosal dissection for noninvasive colorectal lesions with positive horizontal resection margins (R-ESD study). Endoscopy 2023; 55:245-251. [PMID: 36228648 PMCID: PMC9974332 DOI: 10.1055/a-1960-3552] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/12/2022] [Indexed: 01/19/2023]
Abstract
UNLABELLED BACKGROUND : During endoscopic submucosal dissection (ESD), the normal mucosa is cut under constant optical control. We studied whether a positive horizontal resection margin after a complete en bloc ESD predicts local recurrence. METHODS In this European multicenter cohort study, patients with a complete en bloc colorectal ESD were selected from prospective registries. Cases were defined by a horizontal resection margin that was positive or indeterminate for dysplasia (HM1), whereas controls had a free resection margin (HM0). Low risk lesions with submucosal invasion (T1) and margins free of carcinoma were analyzed separately. The main outcome was local recurrence. RESULTS From 928 consecutive ESDs (2011-2020), 354 patients (40 % female; mean age 67 years, median follow-up 23.6 months), with 308 noninvasive lesions and 46 T1 lesions, were included. The recurrence rate for noninvasive lesions was 1/212 (0.5 %; 95 %CI 0.02 %-2.6 %) for HM0 vs. 2/96 (2.1 %; 95 %CI 0.57 %-7.3 %) for HM1. The recurrence rate for T1 lesions was 1/38 (2.6 %; 95 %CI 0.14 %-13.5 %) for HM0 vs. 2/8 (25 %; 95 %CI 7.2 %-59.1 %) for HM1. CONCLUSION A positive horizontal resection margin after an en bloc ESD for noninvasive lesions is associated with a marginal nonsignificant increase in the local recurrence rate, equal to an ESD with clear horizontal margins. This could not be confirmed for T1 lesions.
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Affiliation(s)
- Krijn J. C. Haasnoot
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Francisco Baldaque-Silva
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
- Pedro Hispano Hospital, Advanced Endoscopy Center Carlos Moreira da Silva, Porto, Portugal
| | - Arjun Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Mariana Figueiredo Ferreira
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - João Santos-Antunes
- Department of Gastroenterology and Hepatology, University Hospital Center of São João, Porto, Portugal
- IPATIMUP/i3S, University of Porto, Porto, Portugal
| | - Emanuel Dias
- Department of Gastroenterology and Hepatology, University Hospital Center of São João, Porto, Portugal
| | - Masami Omae
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Laurelle van Tilburg
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hao Dang
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jurjen J. Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Leon M. G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Zheng L, Jiang L, Li D, Chen L, Jiang C, Xie L, Zhou L, Huang J, Liu M, Wang W. Antimicrobial prophylaxis in patients undergoing endoscopic mucosal resection for 10- to 20-mm colorectal polyps: A randomized prospective study. Medicine (Baltimore) 2022; 101:e31440. [PMID: 36550912 PMCID: PMC9771180 DOI: 10.1097/md.0000000000031440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND PURPOSE Endoscopic mucosal resection (EMR) is frequently used for the removal of colorectal neoplasms. However, the use of prophylactic antibiotics in patients undergoing EMR is debatable. The aim of this randomized controlled trial was to assess whether antimicrobial prophylaxis is crucial in the perioperative period of EMR, especially for 10- to 20-mm lesions in this setting. METHODS Two hundred and sixty-four patients were randomized equally into 2 groups, the antibiotic (cefixime) group and the control group. The occurrence of adverse events was examined at 1 to 3 days after EMR. Plasma levels of inflammatory markers were analyzed at pre-operation, 1 day post-operation and 3 days post-operation. Blood samples collected at 1 day post-operation were used for culture. RESULTS A total of 264 and 268 polyps were removed by EMR in the antibiotic group and the control group, respectively. There were 5 cases of fever, with 2 in the antibiotic group and 3 in the control group. In the antibiotic group, 12 patients had abdominal pain and 10 suffered bleeding, whereas in the control group, abdominal pain and bleeding were observed in 10 and 11 patients, respectively. There were no significant differences in the proportion of patients with fever or the incidences of postoperative complications between the groups. No significant differences between the groups were reported in plasma levels of white blood cell count, erythrocyte sedimentation rate, C-reactive protein or procalcitonin at pre-operation or post-operation. No patients provided positive blood cultures. CONCLUSIONS The use the prophylactic antibiotics for EMR procedures in the perioperative period is no longer required when the lesions are 10 to 20 mm in size.
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Affiliation(s)
- Linfu Zheng
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
- Department of Gastroenterology, 900th Hospital of PLA, Fuzhou, China
- Department of Gastroenterology, Oriental Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Liping Jiang
- Meng Chao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Dazhou Li
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
- Department of Gastroenterology, 900th Hospital of PLA, Fuzhou, China
- Department of Gastroenterology, Oriental Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Longping Chen
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
- Department of Gastroenterology, 900th Hospital of PLA, Fuzhou, China
| | - Chuanshen Jiang
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
- Department of Gastroenterology, 900th Hospital of PLA, Fuzhou, China
| | - Longke Xie
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Linxin Zhou
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Jianxiao Huang
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Meiyan Liu
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Wen Wang
- Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Fuzhou, China
- Department of Gastroenterology, 900th Hospital of PLA, Fuzhou, China
- Department of Gastroenterology, Oriental Hospital Affiliated to Xiamen University, Fuzhou, China
- *Correspondence: Wen Wang, Department of Gastroenterology, 900th Hospital of PLA, Fujian Medical University, Oriental Hospital Affiliated to Xiamen University, Fuzhou 350025, China (e-mail: )
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Nakajima T, Sakamoto T, Hori S, Yamada S, Ikematsu H, Harada K, Chiu HM, Kiriyama S, Michida T, Hotta K, Sakamoto N, Abe T, Chino A, Fukuzawa M, Kobayashi N, Fukase K, Matsuda T, Murakami Y, Ishikawa H, Saito Y. Optimal surveillance interval after piecemeal endoscopic mucosal resection for large colorectal neoplasia: a multicenter randomized controlled trial. Surg Endosc 2022; 36:515-525. [PMID: 33569725 DOI: 10.1007/s00464-021-08311-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/09/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Colorectal neoplastic lesions (≥ 20 mm) are commonly treated via piecemeal endoscopic mucosal resection (p-EMR) but have a high rate of local recurrence. We aimed to clarify the optimal surveillance interval after p-EMR for these neoplasias. METHODS In this multicenter (15 participating institutions) prospective, randomized trial, 180 patients recruited over a 4-year period and were classified based on tumor location, tumor diameter, histological diagnosis, institution, and number of resected specimens. The patients underwent curative p-EMR followed by scheduled surveillance colonoscopy at 3, 6, 12, and 24 months after p-EMR (group A; n = 90) or at 6, 12, and 24 months after p-EMR (group B; n = 90). The primary endpoint was cumulative local recurrence at 6 months after p-EMR. Secondary endpoints included local recurrence and the cumulative surgical resection rate of recurrent tumors during the 24-month follow-up period. RESULTS The median tumor diameter was 25 mm (IQR 20-30). Six months after p-EMR, 12 and 6 local recurrences were noted in groups A and B, which corresponded to 13 and 8 recurrences, respectively, during the 24-month surveillance period. The primary and secondary endpoints of recurrence were not significantly different between the groups on either intention-to-treat or per-protocol analysis; no surgery case was observed in group B when a strict surveillance protocol of 6-, 12-, and 24-month follow-up post-EMR was followed. CONCLUSIONS For patients who underwent p-EMR for neoplastic lesions, additional postprocedural 3-month surveillance did not show superior results in detecting recurrence compared with a 6-month surveillance interval. CLINICAL TRIAL REGISTRATION UMIN000015740.
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Affiliation(s)
- Takeshi Nakajima
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shinichiro Hori
- Department of Endoscopy, NHO Shikoku Cancer Center, Matsuyama, Ehime, Japan
| | - Shinya Yamada
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Keita Harada
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Tomoki Michida
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kinichi Hotta
- Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University Hospital, Tokyo, Japan
| | - Takashi Abe
- Gastroenterology Center, Hanwa Sumiyoshi General Hospital, Osaka, Japan
| | - Akiko Chino
- Gastroenterological Medicine, Cancer Institute Hospital, Ariake, Tokyo, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Nozomu Kobayashi
- Department of Gastroenterology, Tochigi Cancer Center, Utsunomiya, Tochigi, Japan
| | | | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | | | - Hideki Ishikawa
- Department of Molecular-Targeting Cancer Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Nishimura T, Oka S, Tanaka S, Kamigaichi Y, Tamari H, Shimohara Y, Okamoto Y, Inagaki K, Matsumoto K, Tanaka H, Yamashita K, Ninomiya Y, Kitadai Y, Arihiro K, Chayama K. Long-term prognosis after endoscopic submucosal dissection for colorectal tumors in patients aged over 80 years. BMC Gastroenterol 2021; 21:324. [PMID: 34425746 PMCID: PMC8381532 DOI: 10.1186/s12876-021-01899-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background In Japan, endoscopic submucosal dissection (ESD) is standardized for large colorectal tumors. However, its validity in the elderly population is unclear. We aimed to evaluate the safety and efficacy of ESD for colorectal tumors in elderly patients aged over 80 years.
Methods ESD was performed on 178 tumors in 165 consecutive patients aged over 80 years between December 2008 and December 2018. We retrospectively evaluated the clinicopathological characteristics and clinical outcomes of ESD. We also assessed the prognosis of 160 patients followed up for more than 12 months. Results The mean patient age was 83.7 ± 3.1 years. The number of patients with comorbidities was 100 (62.5%). Among all patients, 106 (64.2%) were categorized as class 1 or 2 according to the American Society of Anesthesiologists classification of physical status (ASA-PS), and 59 (35.8%) were classified as class 3. The mean procedure time was 97.7 ± 79.3 min. The rate of histological en bloc resection was 93.8% (167/178). Delayed bleeding in 11 cases (6.2%) and perforation in 7 cases (3.9%) were treated conservatively. The 5-year survival rate was 89.9%. No deaths from primary disease (mean follow-up time: 35.3 ± 27.5 months) were observed. Overall survival rates were significantly lower in the non-curative resection group that did not undergo additional surgery than in the curative resection group (P = 0.0152) and non-curative group that underwent additional surgery (P = 0.0259). Overall survival rates were higher for ASA-PS class 1 or 2 patients than class 3 patients (P = 0.0105). Metachronous tumors (> 5 mm) developed in 9.4% of patients. Conclusions ESD for colorectal tumors in patients aged over 80 years is safe. Colorectal cancer-associated deaths were prevented although comorbidities pose a high risk of poor prognosis.
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Affiliation(s)
- Tomoyuki Nishimura
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, 1-2-3, Kasumi, Hiroshima, 734-8551, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, 1-2-3, Kasumi, Hiroshima, 734-8551, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuki Kamigaichi
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirosato Tamari
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | | | - Yuki Okamoto
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Katsuaki Inagaki
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Kenta Matsumoto
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Ken Yamashita
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuki Ninomiya
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuhiko Kitadai
- Department of the Faculty of Human Culture and Science, Prefectural University of Hiroshima, Hiroshima, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, 1-2-3, Kasumi, Hiroshima, 734-8551, Japan
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10
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Chung HG, Goh MJ, Kim ER, Hong SN, Kim TJ, Chang DK, Kim YH. Recurrence pattern and surveillance strategy for rectal neuroendocrine tumors after endoscopic resection. J Gastroenterol Hepatol 2021; 36:968-973. [PMID: 32864790 DOI: 10.1111/jgh.15231] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/06/2020] [Accepted: 08/21/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Endoscopic resection is highly effective treatment option for rectal neuroendocrine tumors (NETs) as they usually present as small localized tumors. However, there are no well-established surveillance strategies following endoscopic resection. We established our own protocol for the surveillance of rectal NETs after endoscopic resection since 2013. This study aimed to assess the outcome and to optimize the surveillance strategies after endoscopic resection. METHODS We retrospectively analyzed the data of patients with endoscopically treated rectal NETs between January 2013 and April 2018 at Samsung Medical Center. We analyzed 337 patients with a median follow-up duration of 35.0 months (min-max: 12.0-88.3). RESULTS A total of 329 (97.6%) patients had tumors ≤ 1 cm in size, and eight (2.4%) patients had tumors > 1 cm in diameter. Synchronous rectal NETs were diagnosed in nine (2.7%) patients. Thirteen (3.9%) patients were identified as having positive resection margins. Regardless of the salvage treatment, none of these patients developed recurrence. Metachronous rectal NETs were diagnosed in nine (2.7%) patients. Metachronous lesions were associated with the number of synchronous lesions at initial diagnosis (P < 0.001, hazard ratio = 1.75, 95% confidence interval = 1.38-2.23). Extracolonic metastasis was not detected in this study. CONCLUSION Although initial screening for detecting metastatic lesions using computed tomography is recommended, repeated imaging for detecting extracolonic recurrence was not necessary for small non-metastatic rectal NETs. However, regular endoscopic follow-up seems reasonable, especially in case of synchronous rectal NETs, for detecting metachronous rectal NETs.
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Affiliation(s)
- Hye Gyo Chung
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Myung Ji Goh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae Jun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Long-term outcomes and surveillance timing of patients with large non-pedunculated colorectal polyps with histologically incomplete resection in endoscopic resection. Surg Endosc 2021; 36:1369-1378. [PMID: 33689013 DOI: 10.1007/s00464-021-08419-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Histologically incomplete resection of large colorectal polyps is frequently encountered; however, the long-term outcomes or surveillance timing is not well known. We evaluated the incidence rate and time of recurrence of these cases during a long-term follow-up. METHODS We performed a retrospective analysis of patients who underwent endoscopic resection for large (≥10 mm in size) non-pedunculated colorectal polyps at a tertiary academic hospital. Patients who had positive or indeterminate lateral margin in the histology and underwent completed surveillance colonoscopy first at 3-12 months and finally at ≥2 years after initial resection were included. RESULTS Of 169 polyps (148 patients), 37 (21.9%) and 132 (78.1%) polyps had positive and indeterminate lateral margins, respectively. The median time intervals of the first and last surveillance from the initial resection were 6 (3-12) and 48 (24-114) months, respectively. The recurrence rate was 9.5% (16/169) during follow-up, and the mean time to recurrence was 31.9 months. Thirteen (81.3%) polyps recurred after ≥12 months. Most (14/16, 87.5%) recurrent polyps were benign, and 2 cases had advanced cancer. The only factor that was significantly associated with recurrence in the univariate and multivariate analyses was ≥3 piecemeal resections (odds ratio in the multivariate analysis, 16.92; 95% CI, 1.19-241.81; p = 0.037). CONCLUSION During the long-term follow-up, the only factor that was significantly associated with recurrence was ≥3 piecemeal resections, and most recurrences occurred after ≥12 months. Thus, a histologically incomplete resection with ≤2 piecemeal resections and no findings of suspected submucosal cancer may be considered as complete resection, and these patients may undergo first surveillance colonoscopy after 1-2 years.
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12
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Park EY, Baek DH, Song GA, Kim GH, Lee BE, Park DY. Long-term outcomes of endoscopically resected laterally spreading tumors with a positive histological lateral margin. Surg Endosc 2019; 34:3999-4010. [PMID: 31605216 DOI: 10.1007/s00464-019-07187-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND With advances in diagnostic endoscopy, the incidence of superficial colorectal tumors, including laterally spreading tumors (LSTs), has increased. However, little is known about the long-term results of LSTs with positive lateral margin after endoscopic treatment. This study aimed to evaluate the long-term clinical outcomes and risk factors for local recurrence of LSTs with positive lateral margin after initial endoscopic resection. METHODS We performed a retrospective analysis of the medical records of 324 patients who had 363 LSTs with positive lateral margin after endoscopic resection at a tertiary academic medical center. The medical records from 2011 to 2015 were analyzed. Local recurrence was confirmed through endoscopic finding and subsequent biopsy analysis. We assessed the local recurrence rate and performed multivariate analyses to identify the factors associated with local recurrence. RESULTS Follow-up colonoscopy was performed in 176 of 363 LSTs. The local recurrence rate was 6.3% (11/176), with a median (interquartile range [IQR]) follow-up period of 19.8 (12.4-46.5) months. In multivariate analysis, local recurrence was associated with piecemeal resection (odds ratio [OR] 6.62, 95% confidence interval [CI] 1.28-34.33; p = 0.024) and inversely associated with thermal ablation (OR 0.033, 95% CI 0.00-0.45; p = 0.011). At surveillance colonoscopy, histology of the recurrent tumor was adenoma in 10 (90.9%) of 11; these were treated endoscopically. CONCLUSIONS In this retrospective study, we found that endoscopically resected LSTs with positive lateral margin have a low recurrence rate. Piecemeal resection was associated with higher local recurrence, and thermal ablation was inversely associated with local recurrence. Endoscopic resection with positive lateral margin combined with thermal ablation leads to a low recurrence rate.
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Affiliation(s)
- Eun Young Park
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49421, South Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49421, South Korea.
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49421, South Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49421, South Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49421, South Korea
| | - Do Youn Park
- Department of Pathology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
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Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery. J Gastrointest Surg 2019; 23:1874-1883. [PMID: 30306452 DOI: 10.1007/s11605-018-3980-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up. METHOD Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence. RESULTS TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis. CONCLUSION TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.
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14
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Takezawa T, Hayashi Y, Shinozaki S, Sagara Y, Okada M, Kobayashi Y, Sakamoto H, Miura Y, Sunada K, Lefor AK, Yamamoto H. The pocket-creation method facilitates colonic endoscopic submucosal dissection (with video). Gastrointest Endosc 2019; 89:1045-1053. [PMID: 30716306 DOI: 10.1016/j.gie.2019.01.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Colonic endoscopic submucosal dissection (ESD) is more difficult than rectal ESD because of poor maneuverability of the endoscope due to physiologic flexion, peristalsis, and respiratory movements. The aim of this study was to assess the usefulness of the pocket-creation method (PCM) for colonic ESD compared with the conventional method (CM) regardless of lesion shape or location. METHODS A total of 887 colorectal lesions were treated by ESD. Of 887 lesions, 271 rectal lesions, 72 lesions smaller than 20 mm in diameter, and 1 non-neoplastic lesion were excluded. This is a retrospective chart review of the remaining 543 colon lesions in 512 patients. We divided them into the PCM group (n = 280) and the CM group (n = 263). The primary outcome was the en bloc resection rate. Secondary outcomes were R0 resection (en bloc resection with negative margin), adverse events, dissection time (in minutes), and dissection speed (in mm2/min). RESULTS The PCM group achieved a significantly higher en bloc resection rate (PCM, 100% [280/280], vs CM, 96% [253/263]; P < .001) and R0 resection rate (91% [255/280] vs 85% [224/263], respectively; P = .033) than the CM group. Dissection time was similar (69.5 ± 44.4 vs 78.7 ± 62.6 minutes, P = .676). Dissection speed was significantly faster with the PCM than with the CM (23.5 ± 11.6 vs 20.9 ± 13.6 mm2/min, P < .001). The incidence of adverse events was similar (perforation, 2% vs 4% [P = .152], and delayed bleeding, 2% vs 1% [P = .361]). CONCLUSIONS Colonic ESD using the PCM significantly improves the rates of en bloc resection and R0 resection and facilitates rapid dissection.
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Affiliation(s)
- Takahito Takezawa
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshikazu Hayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Satoshi Shinozaki
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan; Shinozaki Medical Clinic, Utsunomiya, Japan
| | - Yuichi Sagara
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Masahiro Okada
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yasutoshi Kobayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Hirotsugu Sakamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshimasa Miura
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Keijiro Sunada
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | | | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
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Kim JY, Han SJ, Jung Y, Cho YS, Chung IK, Lee TH, Park SH, Cho HD, Kim SJ, Hwangbo Y. The relationship between local recurrence and positive lateral margin after en bloc resection of colorectal neoplasm. Scand J Gastroenterol 2018; 53:1541-1546. [PMID: 30600737 DOI: 10.1080/00365521.2018.1547419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The factors associated with recurrence of colonic neoplasm after endoscopic resection with a positive lateral margin are not well known. Thus, we evaluate the relationship between recurrence and positive lateral margin after endoscopic en bloc resection of colorectal neoplasm. METHODS A retrospective review of 9302 patients who underwent colonic endoscopic resection from January 2008 to January 2015. Of these, a total of 76 patients with positive lateral margins with clear evidence of the its location on endoscopic picture after endoscopic en bloc resection of colorectal neoplasm (>10 mm) were included. RESULTS Ten of 76 (13.2%) patients experienced recurrence during the follow-up period (mean f/u month, 21.7 ± 15.6). In cases with positive lateral margins, the 3- and 5-year local recurrence rate of colorectal neoplasm was 28.1% and 40.1%, respectively. The histological features of the recurrence group were as follows: one case of adenocarcinoma [from low-grade adenoma (LGA)]; two cases of high-grade adenoma (HGA) (one from HGA and one from LGA); and seven cases of LGA (four from adenocarcinoma, two from LGA, and one from HGA). The mean age of patients, locations of the lesions, and histologic type were not significantly associated with local recurrence. In multivariate Poisson regression analyses, total length of lateral margin involvement ≥8 mm (relative risk 12.51; 95% CI 1.11-140.34, p = .040) was a significant predictor of local recurrence. CONCLUSIONS Positive lateral margins ≥8 mm may be a reliable predictor of local recurrence after endoscopic en bloc resection of colorectal neoplasm.
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Affiliation(s)
- Jae Yun Kim
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Su Jung Han
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Yunho Jung
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Young Sin Cho
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Il-Kwun Chung
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Tae Hoon Lee
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Sang-Heum Park
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Hyun Deuk Cho
- b Department of Pathology , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Sun-Joo Kim
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Young Hwangbo
- c Department of Preventive Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
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Yamamoto K, Shimoda R, Ogata S, Hara M, Ito Y, Tominaga N, Nakayama A, Sakata Y, Tsuruoka N, Iwakiri R, Fujimoto K. Perforation and Postoperative Bleeding Associated with Endoscopic Submucosal Dissection in Colorectal Tumors: An Analysis of 398 Lesions Treated in Saga, Japan. Intern Med 2018; 57:2115-2122. [PMID: 29607956 PMCID: PMC6120842 DOI: 10.2169/internalmedicine.9186-17] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective The aim of this study was to clarify the safety of colorectal endoscopic submucosal dissection (ESD) during the era of health insurance coverage starting from April 2012 in Japan. Methods Between April 2012 and May 2016, ESD was applied to 398 lesions in 373 patients. Risk factors for serious complications of colorectal ESD, perforation and post-ESD bleeding, were evaluated focusing on the resected specimen size, location, growth pattern, invasion depth, histopathology, postoperative clipping, and procedure time. In addition, the relationship between serious complications and patients' background characteristics was analyzed. Results Among 373 patients, perforation occurred in 12 patients and post-ESD bleeding in 19 patients. A univariate analysis showed that the risk factors for perforation were the lesion size, the resected specimen size, and a long operation time. A multivariate analysis showed that a long operation time was a risk factor for perforation during colorectal ESD. A univariate analysis indicated that significant risk factors for postoperative bleeding were a long operation time, rectal lesion, and cancer. All patients with serious complications were treated by an endoscopic procedure without blood transfusion or the need to convert to open surgery. Conclusion The present study suggests that colorectal ESD may be accepted with relative safety in Japan as a common therapeutic approach for early colorectal cancer.
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Affiliation(s)
- Koji Yamamoto
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
- Department of Gastroenterology, Saga Prefectural Medical Center, Japan
| | - Ryo Shimoda
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
| | - Shinichi Ogata
- Department of Gastroenterology, Saga Prefectural Medical Center, Japan
| | - Megumi Hara
- Departments of Preventive Medicine, Saga Medical School, Saga Medical School, Japan
| | - Yoichiro Ito
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
- Department of Gastroenterology, Saga Prefectural Medical Center, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Prefectural Medical Center, Japan
| | - Atsushi Nakayama
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
- Department of Gastroenterology, Saga Prefectural Medical Center, Japan
| | - Yasuhisa Sakata
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
| | - Nanae Tsuruoka
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
| | - Ryuichi Iwakiri
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
| | - Kazuma Fujimoto
- Departments of Internal Medicine, Saga Medical School, Saga Medical School, Japan
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Lee S, Kim J, Soh JS, Bae J, Hwang SW, Park SH, Ye BD, Byeon JS, Myung SJ, Yang SK, Yang DH. Recurrence rate of lateral margin-positive cases after en bloc endoscopic submucosal dissection of colorectal neoplasia. Int J Colorectal Dis 2018. [PMID: 29532207 DOI: 10.1007/s00384-018-3012-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to evaluate the recurrence rate of colorectal neoplasia showing histologic lateral margin involvement after en bloc endoscopic submucosal dissection (ESD). METHODS We reviewed 527 colorectal lesions that were removed by en bloc ESD from 2005 to 2013 and followed by endoscopy. Based on the postprocedural pathologic reports, the lesions were categorized as follows: lesions with clear deep and positive lateral margins (n = 63) and lesions with R0 resection (n = 299). RESULTS The tumor size was 45.7 ± 21.1 mm in the lateral margin-positive group and 30.6 ± 15.1 in the R0 group (P < 0.001). Procedure time was longer in the lateral margin-positive group than in the R0 group (94.3 ± 75.1 vs. 54.1 ± 48.9 min; P < 0.001). Lateral margin positivity was associated with ESD time ≥ 120 min in the multivariate analysis. Compared with 0-I morphology, LST-G was significantly associated with the lateral margin positivity. The volume of ESD experience in endoscopists may also be associated with the lateral margin positivity. Histologic reassessment of the specimen suggested that 32.2% of lateral margin-positive cases based on the initial pathology report were false-positive lateral margin involvement. The 5-year cumulative recurrence rate was 0.6% in the R0 group and 5% in the margin-positive group (P = 0.198). CONCLUSIONS The local recurrence rate was not higher in lateral margin-positive cases than in R0 resection cases if the colorectal epithelial neoplasia was removed in an en bloc manner using ESD. Meticulous pathologic interpretation may reduce unnecessarily frequent surveillance after en bloc ESD.
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Affiliation(s)
- Seohyun Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Seung Soh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jungho Bae
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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18
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Barendse RM, Musters GD, de Graaf EJR, van den Broek FJC, Consten ECJ, Doornebosch PG, Hardwick JC, de Hingh IHJT, Hoff C, Jansen JM, van Milligen de Wit AWM, van der Schelling GP, Schoon EJ, Schwartz MP, Weusten BLAM, Dijkgraaf MG, Fockens P, Bemelman WA, Dekker E. Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study). Gut 2018; 67:837-846. [PMID: 28659349 DOI: 10.1136/gutjnl-2016-313101] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Non-randomised studies suggest that endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM), but EMR might be more cost-effective and safer. This trial compares the clinical outcome and cost-effectiveness of TEM and EMR for large rectal adenomas. DESIGN Patients with rectal adenomas ≥3 cm, without malignant features, were randomised (1:1) to EMR or TEM, allowing endoscopic removal of residual adenoma at 3 months. Unexpected malignancies were excluded postrandomisation. Primary outcomes were recurrence within 24 months (aiming to demonstrate non-inferiority of EMR, upper limit 10%) and the number of recurrence-free days alive and out of hospital. RESULTS Two hundred and four patients were treated in 18 university and community hospitals. Twenty-seven (13%) had unexpected cancer and were excluded from further analysis. Overall recurrence rates were 15% after EMR and 11% after TEM; statistical non-inferiority was not reached. The numbers of recurrence-free days alive and out of hospital were similar (EMR 609±209, TEM 652±188, p=0.16). Complications occurred in 18% (EMR) versus 26% (TEM) (p=0.23), with major complications occurring in 1% (EMR) versus 8% (TEM) (p=0.064). Quality-adjusted life years were equal in both groups. EMR was approximately €3000 cheaper and therefore more cost-effective. CONCLUSION Under the statistical assumptions of this study, non-inferiority of EMR could not be demonstrated. However, EMR may have potential as the primary method of choice due to a tendency of lower complication rates and a better cost-effectiveness ratio. The high rate of unexpected cancers should be dealt with in further studies.
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Affiliation(s)
- Renée M Barendse
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | | | | | | | | | | | - James C Hardwick
- Gastroenterology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Chrisiaan Hoff
- Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Jeroen M Jansen
- Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | | | - Erik J Schoon
- Gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Bas L A M Weusten
- Gastroenterology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Paul Fockens
- Gastroenterology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Evelien Dekker
- Gastroenterology, Academic Medical Centre, Amsterdam, the Netherlands
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19
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Abstract
PUPRPOSE Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options. METHODS A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum. RESULTS Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery. CONCLUSION Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.
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20
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Endoscopic Resection of Cecal Polyps Involving the Appendiceal Orifice: A KASID Multicenter Study. Dig Dis Sci 2017; 62:3138-3148. [PMID: 28936593 DOI: 10.1007/s10620-017-4760-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/08/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic resection of polyps located at the appendiceal orifice (AO) is challenging, and the feasibility and outcomes of endoscopic resection for cecal polyps involving AO are unconfirmed. AIMS We evaluated the feasibility and outcomes of endoscopic resection for cecal polyps involving AO. METHODS In this retrospective, multicenter study involving nine tertiary referral centers, we evaluated 131 patients who underwent endoscopic resection for cecal polyps involving AO. RESULTS The median size of polyps resected was 10 mm (range 3-60 mm). Endoscopic mucosal resection, endoscopic piecemeal mucosal resection, and endoscopic submucosal dissection were performed in 75 (57.3%), 31 (23.7%), and 5 (3.8%) patients, respectively. The en bloc resection rate was 68.7%. Endoscopic complete resection was achieved in 123 lesions (93.9%). Intraprocedural and delayed bleeding occurred in 14 (10.7%) and three patients (2.3%), respectively, and perforation occurred in two patients (1.5%). Seven patients (5.3%) underwent additional surgery because of treatment failure or recurrence. Polyps of ≥20 mm in size showed significantly higher rates of perforation and additional surgery (p < 0.05), and a lower rate of en bloc resection (p < 0.005). Patients with polyps involving ≥75% of AO circumference exhibited a significantly lower rate of en bloc resection (p < 0.001), and significantly higher rates of surgery and recurrence (p < 0.05). Recurrence during follow-up occurred in 12 patients (15.6%); polyps involving ≥75% of AO circumference were an independent risk factor for recurrence. CONCLUSION Endoscopic resection of cecal polyps involving AO is safe and effective in select patients.
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21
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Osera S, Ikematsu H, Fujii S, Hori K, Oono Y, Yano T, Kaneko K. Endoscopic treatment outcomes of laterally spreading tumors with a skirt (with video). Gastrointest Endosc 2017; 86:533-541. [PMID: 28174124 DOI: 10.1016/j.gie.2017.01.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/16/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A "skirt" is a slightly elevated flat lesion with wide pits occasionally observed at the margin of laterally spreading tumors (LSTs). However, the endoscopic treatment outcomes of LSTs with skirts have not been clarified. The aim of this study was to evaluate the endoscopic treatment outcomes of LSTs with skirts. METHODS Between February 2006 and March 2014, 996 LSTs were retrospectively examined to assess the clinicopathologic characteristics, procedure time, en bloc resection rate, R0 resection rate, adverse events, and local recurrence rate of endoscopic submucosal dissection (ESD) and of endoscopic resection. RESULTS Endoscopic treatment was performed in 35 cases of LSTs with skirts (ratio of ESD to endoscopic piecemeal mucosal resection [EPMR], 32:3) and 961 cases of LSTs without skirts (ratio of ESD to EMR to EPMR to polypectomy, 381:275:114:191). LSTs with a skirt were associated with a significantly higher recurrence rate (P < .01). In both ESD and EPMR, LSTs with a skirt were associated with a higher recurrence rate when compared with LSTs without a skirt (odds ratio, 12.7; P = .032, and odds ratio, 12.3; P = .061, respectively). Multivariate analysis demonstrated that the presence of the skirt and piecemeal resection were significant predictors of local recurrence. CONCLUSIONS LSTs with skirts had a significantly higher local recurrence rate after endoscopic treatment compared with LSTs without skirts, especially after EPMR. Therefore, ESD should be recommended as an endoscopic treatment for LSTs with skirts to minimize local recurrence.
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Affiliation(s)
- Shozo Osera
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan; Department of Gastroenterology, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Satoshi Fujii
- Pathology Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Keisuke Hori
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yasuhiro Oono
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kazuhiro Kaneko
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
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22
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Oh DM, Lee JK, Kim H, Park CK, Jung JK, Kim DJ, Chung YJ, Kim TH, Park MI, Park JP. Local Recurrence and Its Risk Factor after Incomplete Resection of Colorectal Advanced Adenomas: A Single Center, Retrospective Study. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 70:33-38. [PMID: 28728314 DOI: 10.4166/kjg.2017.70.1.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background/Aims Colonoscopy can detect precancerous lesions, which can subsequently be removed and reduce incidences of and mortality from colorectal cancer (CRC). However, recently published data have highlighted a significant rate of CRC in patients who previously underwent colonoscopy. Among many reasons, incomplete resection has been considered as a significant contributor. However, to date, there have only been a few studies regarding incompletely resected polyps, especially advanced colorectal adenoma (ACA). Hence, we aimed to evaluate the prognosis of incompletely resected ACA. Methods We retrospectively reviewed the medical records of patients with ACA who had underwent endoscopic treatment with incomplete resection. The primary outcomes were (1) the incomplete resection rate of ACA, as determined by a histopathologic examination and (2) the recurrence rate of incompletely resected ACA. We also investigated the probable contributing factors that may have led to a relapse of incompletely resected ACA. Results A total of 7,105 patients had their colorectal polyps resected by endoscopic treatment, and 2,233 of these were considered as ACA. Of these, 354 polyps (15.8%) were resected incompletely, and only 163 patients were followed-up. Of those followed-up, 31 patients (19.0%) experienced local recurrence. The risk factors for recurrence after incomplete resection were evaluated; age, morphology of adenoma, and use of rescue therapy, such as argon plasma coagulation, were found to be associated with adenoma recurrence. Conclusions Incompletely resected ACA in older patients or in patients with sessile-type adenomas should be monitored strictly, and if incomplete resection is suspected, rescue therapy must be considered.
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Affiliation(s)
- Dae Myung Oh
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jae Kwang Lee
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Hyunsoo Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Chang Keun Park
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jae Kwon Jung
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Dae Jin Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Yun Jin Chung
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Tae Hoon Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Myung Il Park
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jong Pil Park
- Division of Gastroenterology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
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23
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Abdelaziz M, Sayed M. Colonic Laterally Spreading Tumor Diagnosed as an Early Cancer and Treated with Endoscopic Mucosal Resection: A Case Report and Review of Literature. Middle East J Dig Dis 2017; 9:49-54. [PMID: 28316766 PMCID: PMC5308134 DOI: 10.15171/mejdd.2016.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Laterally spreading tumors (LSTs) are generally defined as superficial lesions ≥10 mm in diameter that typically extend laterally rather than vertically along the colonic wall. Such lesions are now increasingly reported because of increased awareness and the introduction of chromo and magnifying colonoscopy. Although the clinicopathological characteristics and the efficacy of endoscopic management of LSTs have been defined in Japanese cohorts, reports from the Middle East are lacking where surgical resection is the mainstay of treatment. We report a case with an LST about 20 cm from anal verge removed by endoscopic mucosal resection. After histopathological evaluation of the removed specimen, we categorized the patient as having high risk early colon cancer. The intensive follow-up as an additional treatment strategy was chosen for the patient. This review addresses the management of early carcinoma in colorectal polyp with reference to proper preoperative assessment, treatment selection with special attention to role of biomarkers, the need for additional treatment on the basis of the presence of risk factors and endoscopic follow-up after treatment.
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Affiliation(s)
- Mohamad Abdelaziz
- Department of Tropical Medicine and Gastroenterology, University of Sohag, Egypt ; Mohamad Dossary Hospital, Saudi Arabia
| | - Motaz Sayed
- Mohamad Dossary Hospital, Saudi Arabia ; Department of Internal Medicine, University of Ein Shams, Egypt
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24
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Lim SH, Levenick JM, Mathew A, Moyer MT, Dye CE, McGarrity TJ. Endoscopic Management of Large (≥2 cm) Non-pedunculated Colorectal Polyps: Impact of Polyp Morphology on Outcomes. Dig Dis Sci 2016; 61:3572-3583. [PMID: 27696095 DOI: 10.1007/s10620-016-4314-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/12/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Referrals for endoscopic management of large non-pedunculated (NP) colorectal polyps have increased as new techniques have emerged. The outcomes for referred large NP polyps based on the polyp morphology were investigated METHODS: A retrospective review of patients referred for large (≥20 mm) NP polyp management from January 2010 through June 2014 was completed. Polyp morphology was classified as either a NP polyp with depression (M1) or NP polyp with no depression (M0). Differences in treatment, histology, adverse events, outcomes at follow-up including residual disease, and need for surgical treatment were determined by morphology for all NP polyps ≥20 mm in size. RESULTS One-hundred and sixty-nine M1 and 136 M0 polyps ≥20 mm were removed endoscopically during the review period. Mean size was 31.9 ± 11.0 mm in M1, and 26.8 ± 9.5 mm in M0 group (p < 0.0001). En bloc resection was possible in 18.3 % of M1 and 30.9 % of M0 lesions (p = 0.011) with endoscopic submucosal dissection used in 13 and 2.2 % of polyps, respectively (p < 0.0001). Residual polyp was found in 26.5 % (27/102) of M1 and 13.6 % (12/88) of M0 patients at surveillance colonoscopy (p = 0.029). On multivariate analysis, piecemeal resection and M1 morphology showed significant association with residual polyp (OR 4.23, 95 % CI 1.23-14.59, p = 0.022, and OR 2.15, 95 % CI 1.004-4.62, p = 0.049, respectively). CONCLUSION Effective endoscopic management of large NP colorectal polyps, especially polyps without depression (M0), can be accomplished in the great majority of patients. Polyp morphology, particularly the presence or absence of depression, is a useful tool which influenced treatment, histology, and outcomes.
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Affiliation(s)
- Seon Hee Lim
- Division of Gastroenterology, Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, 138-984, Korea
| | - John M Levenick
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, HU33, 500 University Drive, Hershey, PA, 17033-0850, USA.
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, HU33, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, HU33, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - Charles E Dye
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, HU33, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - Thomas J McGarrity
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, HU33, 500 University Drive, Hershey, PA, 17033-0850, USA
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25
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Moon CM, Huh KC, Jung SA, Park DI, Kim WH, Jung HM, Koh SJ, Kim JO, Jung Y, Kim KO, Kim JW, Yang DH, Shin JE, Shin SJ, Kim ES, Joo YE. Long-Term Clinical Outcomes of Rectal Neuroendocrine Tumors According to the Pathologic Status After Initial Endoscopic Resection: A KASID Multicenter Study. Am J Gastroenterol 2016; 111:1276-85. [PMID: 27377520 DOI: 10.1038/ajg.2016.267] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 05/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES With advances in diagnostic endoscopy, the detection of rectal neuroendocrine tumors (NETs) has increased. However, clinical outcomes, especially after endoscopic treatment, are still unclear. The aim of this study was to determine the long-term clinical outcomes of endoscopically resected rectal NETs according to the pathologic status after initial resection. METHODS In this large, multicenter, retrospective cohort study, we analyzed the medical records of patients who underwent endoscopic resection of rectal NETs and were followed for ≥24 months at 16 university hospitals. The outcomes of interest were local or distant recurrence and metachronous lesions. RESULTS On the pathologic assessment of 407 patients, the resection margin status was positive in 76 (18.7%) and indeterminate in 72 (17.7%) patients. Patients whose rectal NETs were diagnosed or suspected as NETs before resection showed a much higher complete resection rate than those whose tumors were resected as polyps and then diagnosed (P<0.001). Fourteen patients received salvage treatment at 1.9±2.8 months after initial treatment. During a median follow-up period of 45.0 months, local recurrence occurred in 3 (0.74%) patients, but there was no recurrence in the lymph nodes or distant organs. Metachronous rectal NETs were diagnosed in 3 (0.74%) patients. According to the pathologic status after initial resection, local recurrence and metachronous lesions occurred in 1 (0.4%) and 2 (0.8%) patients, respectively, in the pathologic tumor-free group, whereas they occurred in 2 (1.4%) and 1 (0.7%) patients, respectively, in the indeterminate group. CONCLUSIONS Considering the long-term prognosis including that for recurrences or metachronous lesions, endoscopic resection is an efficient and a safe modality for the treatment of rectal NETs. This treatment may result in favorable clinical outcomes in patients with tumors of indeterminate pathology, as well as in pathologic tumor-free cases after initial resection.
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Affiliation(s)
- Chang Mo Moon
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Kyu Chan Huh
- Department of Internal Medicine, Konyang University College of Medicine, Konyang University Hospital, Daejeon, South Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Hee Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Hye Mi Jung
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seong-Joon Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Boramae Medical Center, Seoul, South Korea
| | - Jin-Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul Hospital, Seoul, South Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, South Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, South Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, South Korea
| | - Sung Jae Shin
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - Eun Soo Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Young-Eun Joo
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea
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26
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Law R, Das A, Gregory D, Komanduri S, Muthusamy R, Rastogi A, Vargo J, Wallace MB, Raju GS, Mounzer R, Klapman J, Shah J, Watson R, Wilson R, Edmundowicz SA, Wani S. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis. Gastrointest Endosc 2016; 83:1248-57. [PMID: 26608129 DOI: 10.1016/j.gie.2015.11.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP. METHODS A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges. RESULTS LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000. CONCLUSIONS Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ananya Das
- Arizona Digestive Health, Gilbert, Arizona, USA
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Raman Muthusamy
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Amit Rastogi
- Division of Gastroenterology, The University of Kansas Hospital, Kansas City, Kansas, USA
| | - John Vargo
- Digestive Diseases Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic-Jacksonville, Jacksonville, Florida, USA
| | - G S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jason Klapman
- Gastrointestinal Oncology Department, Moffitt Cancer Center, Tampa, Florida, USA
| | - Janak Shah
- Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra Watson
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Robert Wilson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Backes Y, Moons LMG, van Bergeijk JD, Berk L, Ter Borg F, Ter Borg PCJ, Elias SG, Geesing JMJ, Groen JN, Hadithi M, Hardwick JCH, Kerkhof M, Mangen MJJ, Straathof JWA, Schröder R, Schwartz MP, Spanier BWM, de Vos Tot Nederveen Cappel WH, Wolfhagen FHJ, Koch AD. Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial. BMC Gastroenterol 2016; 16:56. [PMID: 27229709 PMCID: PMC4882830 DOI: 10.1186/s12876-016-0468-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/14/2016] [Indexed: 02/08/2023] Open
Abstract
Background Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness of ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the short-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the long-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with less need for repeated procedures. Methods This is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than 20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic assessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints are R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical referral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated taking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying used healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional costs per QALY. Discussion If this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and repeated procedures can be prevented for future patients. Trial registration NCT02657044 (Clinicaltrials.gov), registered January 8, 2016.
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Affiliation(s)
- Y Backes
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3508, GA, Utrecht, Netherlands
| | - L M G Moons
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3508, GA, Utrecht, Netherlands.
| | - J D van Bergeijk
- Department of Gastroenterology & Hepatology, Gelderse Vallei, Ede, Netherlands
| | - L Berk
- Department of Gastroenterology & Hepatology, Sint Franciscus, Rotterdam, Netherlands
| | - F Ter Borg
- Department of Gastroenterology & Hepatology, Deventer Hospital, Deventer, Netherlands
| | - P C J Ter Borg
- Department of Gastroenterology & Hepatology, Ikazia, Rotterdam, Netherlands
| | - S G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - J M J Geesing
- Department of Gastroenterology & Hepatology, Diakonessenhuis, Utrecht, Netherlands
| | - J N Groen
- Department of Gastroenterology & Hepatology, Sint Jansdal, Harderwijk, Netherlands
| | - M Hadithi
- Department of Gastroenterology & Hepatology, Maasstad hospital, Rotterdam, Netherlands
| | - J C H Hardwick
- Department of Gastroenterology & Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - M Kerkhof
- Department of Gastroenterology & Hepatology, Groene Hart Hospital, Gouda, Netherlands
| | - M J J Mangen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - J W A Straathof
- Department of Gastroenterology & Hepatology, Máxima Medical Center, Eindhoven, Netherlands
| | - R Schröder
- Department of Gastroenterology & Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - M P Schwartz
- Department of Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - B W M Spanier
- Department of Gastroenterology & Hepatology, Rijnstate hospital, Arnhem, Netherlands
| | | | - F H J Wolfhagen
- Department of Gastroenterology & Hepatology, Albert Schweitzer, Dordrecht, Netherlands
| | - A D Koch
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
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Hassan C, Repici A, Sharma P, Correale L, Zullo A, Bretthauer M, Senore C, Spada C, Bellisario C, Bhandari P, Rex DK. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65:806-20. [PMID: 25681402 DOI: 10.1136/gutjnl-2014-308481] [Citation(s) in RCA: 266] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of endoscopic resection of large colorectal polyps. DESIGN Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed. RESULTS 50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%). CONCLUSIONS Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.
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Affiliation(s)
- C Hassan
- Endoscopy Unit, 'Nuovo Regina Margherita Hospital', Rome, Italy
| | - A Repici
- Digestive Endoscopy Unit, Istituto Clinico Humanitas, Milan, Italy
| | - P Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas, USA
| | | | - A Zullo
- Endoscopy Unit, 'Nuovo Regina Margherita Hospital', Rome, Italy
| | - M Bretthauer
- Department of Health Economy and Health Management, University of Oslo, Oslo, Norway Gastroenterology Unit, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - C Senore
- AOU S Giovanni Battista-CPO Piemonte, SCDO Epidemiologia dei Tumori 2, Turin, Italy
| | - C Spada
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | | | - P Bhandari
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - D K Rex
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
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Shinozaki S, Hayashi Y, Lefor AK, Yamamoto H. What is the best therapeutic strategy for colonoscopy of colorectal neoplasia? Future perspectives from the East. Dig Endosc 2016; 28:289-95. [PMID: 26524602 DOI: 10.1111/den.12566] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/23/2015] [Accepted: 10/29/2015] [Indexed: 12/22/2022]
Abstract
Development and improvement of endoscopic techniques and devices have changed the treatment of colorectal tumors over the last decade. For the treatment of diminutive polyps, the cold snare technique of the West is becoming a promising treatment in the East because of its short procedure time and low rate of delayed bleeding by eliminating the delayed effect of electrocautery. Rather than using piecemeal endoscopic mucosal resection or surgical resection for the treatment of large superficial tumors, the technique of the East of endoscopic submucosal dissection (ESD) achieves a high success rate of en bloc R0 resection, enabling detailed pathological evaluation with less invasive treatment. This procedure should also be useful in the West where large colorectal tumors are more frequent than in the East. Regarding outcomes, however, in the literature, the definition of 'curative resection' remains somewhat inconsistent and long-term outcomes of patients with deep submucosal and/or lymphovascular invasion in the en bloc specimen have not yet been determined. Large prospective, as well as retrospective, studies of these patients are warranted. When colorectal ESD is difficult because of size or location, the pocket-creation method and/or double-balloon-assisted technique may be useful. In the East, high-quality magnified chromoendoscopy is widely available, and endoscopists try to identify focal submucosal invasion. In the West, a systematic evaluation of surveillance for the prevention of colorectal cancer has been done and is highly refined. The East and West have much to learn from each other.
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Affiliation(s)
- Satoshi Shinozaki
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan.,Shinozaki Medical Clinic, Tochigi, Japan
| | - Yoshikazu Hayashi
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | | | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
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Hayashi Y, Shinozaki S, Sunada K, Sato H, Miura Y, Ino Y, Horie H, Fukushima N, Lefor AK, Yamamoto H. Efficacy and safety of endoscopic submucosal dissection for superficial colorectal tumors more than 50 mm in diameter. Gastrointest Endosc 2016; 83:602-7. [PMID: 26341857 DOI: 10.1016/j.gie.2015.08.037] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/02/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The feasibility of endoscopic submucosal dissection (ESD) for large superficial colorectal tumors is undefined. The aim of this study was to assess the outcomes for patients undergoing ESD of superficial colorectal tumors larger than 50 mm. METHODS A total of 472 patients who underwent ESD for superficial colorectal tumors from 2010 to 2014 were enrolled. We retrospectively reviewed their records. RESULTS We compared patients with 20-mm to 50-mm lesions and those with lesions >50 mm regarding demographics, the ESD procedure, and histopathology. Among patients with lesions >50 mm, laterally spreading tumors nongranular and protruded types were uncommon. Histopathologically, deeply invasive (≥1000 μm) submucosal carcinomas were more frequent in lesions >50 mm (14% [10/70] vs 5% [20/402], P < .01). Technically, en bloc resection was successfully accomplished in 99% of patients (69/70). Although the total dissection time for lesions >50 mm was significantly longer than for lesions 20 mm to 50 mm (mean ± SD, 157 ± 114 minutes vs 68 ± 50 min; P < .01), dissection speed for lesions >50 mm was significantly faster than for lesions 20 mm to 50 mm (P < .01). There were no significant differences in en bloc R0 resection rate comparing both groups (>50 mm, 83% vs 20 mm to 50 mm, 87%; P = .31). No perforations or postoperative bleeding occurred in patients with lesions >50 mm. Post-ESD colorectal strictures requiring intervention did not develop in any patient. CONCLUSIONS ESD for superficial colorectal tumors >50 mm is feasible. ESD of these lesions had a high R0 resection rate and a low adverse event rate. En bloc resection by ESD provides adequate pathological specimens and may limit the need for surgical intervention.
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Affiliation(s)
- Yoshikazu Hayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Satoshi Shinozaki
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan; Shinozaki Medical Clinic, Tochigi, Japan
| | - Keijiro Sunada
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hiroyuki Sato
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Yoshimasa Miura
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Yuji Ino
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hisanaga Horie
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | | | - Alan K Lefor
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
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Rutter MD, Chattree A, Barbour JA, Thomas-Gibson S, Bhandari P, Saunders BP, Veitch AM, Anderson J, Rembacken BJ, Loughrey MB, Pullan R, Garrett WV, Lewis G, Dolwani S. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut 2015; 64:1847-73. [PMID: 26104751 PMCID: PMC4680188 DOI: 10.1136/gutjnl-2015-309576] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/25/2015] [Accepted: 05/29/2015] [Indexed: 02/07/2023]
Abstract
These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.
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Affiliation(s)
- Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton on Tees, UK School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Amit Chattree
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Jamie A Barbour
- Department of Gastroenterology, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | | | | | - Rupert Pullan
- Department of Colorectal Surgery, Torbay Hospital, Torquay, UK
| | - William V Garrett
- Department of Colorectal Surgery, Medway Maritime Hospital, Gillingham, UK
| | - Gethin Lewis
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
| | - Sunil Dolwani
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
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Minemura S, Tanaka T, Arai M, Okimoto K, Oyamada A, Saito K, Maruoka D, Matsumura T, Nakagawa T, Katsuno T, Kishimoto T, Yokosuka O. Gene expression profiling of laterally spreading tumors. BMC Gastroenterol 2015; 15:64. [PMID: 26048755 PMCID: PMC4456718 DOI: 10.1186/s12876-015-0295-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Laterally spreading tumors (LSTs) are generally defined as lesions >10 mm in diameter, are characterized by lateral expansion along the luminal wall with a low vertical axis. In contrast to other forms of tumor, LSTs are generally considered to have a superficial growth pattern and the potential for malignancy. We focused on this morphological character of LSTs, and analyzed the gene expression profile of LSTs. METHODS The expression of 168 genes in 41 colorectal tumor samples (17 LST-adenoma, 12 LST-carcinoma, 12 Ip [pedunculated type of the Paris classification)-adenoma, all of which were 10 mm or more in diameter] was analyzed by PCR array. Based on the results, we investigated the expression levels of genes up-regulated in LST-adenoma, compared to Ip-adenoma, by hierarchical and K-means clustering. To confirm the results of the array analysis, using an additional 60 samples (38 LST-adenoma, 22 Ip-adenoma), we determined the localization of the gene product by immunohistochemical staining. RESULT The expression of 129 genes differed in colorectal tumors from normal mucosa by PCR array analysis. As a result of K-means clustering, the expression levels of five genes, AKT1, BCL2L1, ERBB2, MTA2 and TNFRSF25, were found to be significantly up-regulated (p < 0.05) in LST-adenoma, compared to Ip-adenoma. Immunohistochemical analysis showed that the BCL2L1 protein was significantly and meaningfully up-regulated in LST-adenoma compared to Ip-adenoma (p = 0.010). With respect to apoptosis status in LST-Adenoma, it assumes that BCL2L1 is anti-apoptotic protein, the samples such as BCL2L1 positive and TUNEL negative, or BCL2L1 negative and TUNEL positive are consistent with the assumption. 63.2 % LST-adenoma samples were consistent with the assumption. CONCLUSIONS LSTs have an unusual profile of gene expression compared to other tumors and BCL2L1 might be concerned in the organization of LSTs.
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Affiliation(s)
- Shoko Minemura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Takeshi Tanaka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Kenichiro Okimoto
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Arata Oyamada
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Keiko Saito
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Daisuke Maruoka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Tomoaki Matsumura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Tomoo Nakagawa
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Tatsuro Katsuno
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Takashi Kishimoto
- Department of Molecular Pathology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8670, Japan.
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Arezzo A, Arolfo S, Allaix ME, Munoz F, Cassoni P, Monagheddu C, Ricardi U, Ciccone G, Morino M. Results of Neoadjuvant Short-Course Radiation Therapy Followed by Transanal Endoscopic Microsurgery for T1-T2 N0 Extraperitoneal Rectal Cancer. Int J Radiat Oncol Biol Phys 2015; 92:299-306. [DOI: 10.1016/j.ijrobp.2015.01.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 01/07/2015] [Accepted: 01/20/2015] [Indexed: 10/23/2022]
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Makazu M, Sakamoto T, So E, Otake Y, Nakajima T, Matsuda T, Kushima R, Saito Y. Relationship between indeterminate or positive lateral margin and local recurrence after endoscopic resection of colorectal polyps. Endosc Int Open 2015; 3:E252-7. [PMID: 26171439 PMCID: PMC4486031 DOI: 10.1055/s-0034-1391853] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 02/13/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Although endoscopic resection is widely used for the treatment of superficial colorectal neoplasms, the rate of local recurrence of lesions with a positive or indeterminate lateral margin on histologic evaluation is unclear. We aimed to demonstrate the relationship between lateral margin status and local recurrence after the endoscopic resection of intramucosal colorectal neoplasms. PATIENTS AND METHODS We retrospectively collected the clinical and pathologic data for 844 endoscopically resected colorectal intramucosal neoplasms with a size of 10 mm or larger. We investigated the relationship between the local recurrence rate and the lateral margin status (categorized as LM0 [negative], LM1 [positive], or LMX [indeterminate]). RESULTS In total, 389 lesions were evaluated as LM0 and showed no local recurrence. Of the 455 lesions evaluated as LMX or LM1, 30 showed local recurrence within a median period of 6.3 months (range, 1.7 - 48.1) from the initial endoscopic resection. The local recurrence rate of the en bloc-LMX group (2.2 %) was significantly lower than that of the piecemeal-LMX group (15.2 %). Of the 30 cases of recurrence, 28 were successfully treated with a second endoscopic resection. Of the two lesions that showed further recurrence, one was treated with a third endoscopic resection, whereas the other - which was a piecemeal-LMX lesion - was eventually diagnosed as invasive cancer and treated with surgery. CONCLUSIONS The local recurrence rate was lower in the en bloc-LMX group than in the piecemeal-LMX group. Thus, we believe that en bloc-LMX lesions that are completely and confidently resected endoscopically can be treated as en bloc-LM0 lesions.
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Affiliation(s)
- Makomo Makazu
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan ,Corresponding author Taku Sakamoto, MD Endoscopy Division National Cancer Center Hospital5-1-1 Tsukiji, Chuo-kuTokyo 104-0045Japan+81-3-3545-3567
| | - Eriko So
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yosuke Otake
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Nakajima
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Ryoji Kushima
- Pathology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Devaraj B, Kaiser AM. Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms. World J Surg Proced 2015; 5:1-13. [DOI: 10.5412/wjsp.v5.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/21/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
Abstract
Transanal surgery has and continues to be well accepted for local excision of benign rectal disease not amenable to endoscopic resection. More recently, there has been increasing interest in applying transanal surgery to local resection of early malignant disease. In addition, some groups have started utilizing a transanal route in order to accomplish total mesorectal excision (TME) for more advanced rectal malignancies. We aim to review the role of various transanal and endoscopic techniques in the local resection of benign and malignant rectal disease based on published trial data. Preliminary data on the use of transanal platforms to accomplish TME will also be highlighted. For endoscopically unresectable rectal adenomas, transanal surgery remains a widely accepted method with minimal morbidity that avoids the downsides of a major abdomino-pelvic operation. Transanal endoscopic microsurgery and transanal minimally invasive surgery offer improved visualization and magnification, allowing for finer and more precise dissection of more proximal and larger rectal lesions without compromising patient outcome. Some studies have demonstrated efficacy in utilizing transanal platforms in the surgical management of early rectal malignancies in selected patients. There is an overall higher recurrence rate with transanal surgery with the concern that neither chemoradiation nor salvage surgery may compensate for previous approach and correct the inferior outcome. Application of transanal platforms to accomplish transanal TME in a natural orifice fashion are still in their infancy and currently should be considered experimental. The current data demonstrate that transanal surgery remains an excellent option in the surgical management of benign rectal disease. However, care should be used when selecting patients with malignant disease. The application of transanal platforms continues to evolve. While the new uses of transanal platforms in TME for more advanced rectal malignancy are exciting, it is important to remain cognizant and not sacrifice long term survival for short term decrease in morbidity and improved cosmesis.
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Fujiya M, Tanaka K, Dokoshi T, Tominaga M, Ueno N, Inaba Y, Ito T, Moriichi K, Kohgo Y. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81:583-95. [PMID: 25592748 DOI: 10.1016/j.gie.2014.07.034] [Citation(s) in RCA: 264] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR and endoscopic submucosal dissection (ESD) are used frequently to remove colon neoplasms. However, the predominance of these procedures has not yet been thoroughly explored. OBJECTIVE To compare the efficacy and adverse events related to EMR with those related to ESD for colon neoplasms. DESIGN A meta-analysis of 8 studies published between 2005 and 2013. SETTING Multicenter review. PATIENTS Patients from 8 studies yielding 2299 lesions. INTERVENTIONS EMR or ESD. MAIN OUTCOME MEASUREMENTS En bloc resection, curative resection, recurrence, and adverse events. RESULTS The pooled odds ratios (OR) (OR [95% confidence interval]) for the tumor size, length of the procedure, en bloc resection, curative resection, recurrence, additional surgery, delayed bleeding, and perforation by ESD versus EMR were 7.38 (6.42-8.34), 58.07 (36.27-79.88), 6.84 (3.30-14.18), 4.26 (3.77-6.57), 0.08 (0.04-0.17), 2.16 (1.16-4.03), 0.85 (0.45-1.60), and 4.96 (2.79-8.85), respectively. LIMITATIONS This analysis included only nonrandomized studies. CONCLUSION The size of the tumor and rate of en bloc resection and curative resection were higher, and the rate of recurrence was lower in the ESD group versus the EMR group. However, in the ESD group, the procedure was longer, and the rate of additional surgery and perforation was higher, suggesting that the indications for ESD should therefore be rigorously determined in order to avoid such problems.
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Affiliation(s)
- Mikihiro Fujiya
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kazuyuki Tanaka
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tatsuya Dokoshi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Motoya Tominaga
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuhiro Ueno
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuhei Inaba
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takahiro Ito
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kentaro Moriichi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yutaka Kohgo
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Irani S. Hot avulsion: a modification of an existing technique for the management of nonlifting areas of a polyp. Will it give us the lift we need? Gastrointest Endosc 2014; 80:889-91. [PMID: 25436400 DOI: 10.1016/j.gie.2014.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/08/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Shayan Irani
- Department of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington, USA
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Kaimakliotis PZ, Chandrasekhara V. Endoscopic mucosal resection and endoscopic submucosal dissection of epithelial neoplasia of the colon. Expert Rev Gastroenterol Hepatol 2014; 8:521-31. [PMID: 24661135 DOI: 10.1586/17474124.2014.902305] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic mucosal resection (EMR) with curative intent has evolved into a safe and effective technique and is currently the gold standard for management of large colonic epithelial neoplasms. Piecemeal EMR is associated with a high risk of local recurrence requiring vigilant surveillance and repeat interventions. Endoscopic submucosal dissection (ESD) was introduced in Japan for the management of early gastric cancer, and has recently been described for en bloc resection of colonic lesions greater than 20 mm. En bloc resection allows accurate histological assessment of the depth of invasion, minimizes the risk of local recurrence and helps determine additional therapy. Morphologic classification of lesions prior to resection allows prediction of depth of invasion and risk of nodal metastasis, allowing selection of the appropriate intervention. This review provides an overview of the assessment of epithelial neoplasms of the colon and the application of EMR and ESD techniques in their management.
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Affiliation(s)
- Pavlos Z Kaimakliotis
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, PA, USA
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Arlen M, Arlen P, Coppa G, Crawford J, Wang X, Saric O, Dubeykovskiy A, Molmenti E. Monoclonal antibodies that target the immunogenic proteins expressed in colorectal cancer. World J Gastrointest Oncol 2014; 6:170-176. [PMID: 24936227 PMCID: PMC4058724 DOI: 10.4251/wjgo.v6.i6.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/26/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
In an attempt to improve upon the end results obtained in treating colorectal cancer it was apparent that the earlier the diagnosis that could be obtained, the better the chance for obtaining desired results. In the case of more advanced tumors typified by later stage colorectal cancer, surgical debulking is an important part of the treatment strategy. Here the use of additional therapeutic modalities including chemotherapy and present day immunotherapy has failed to accomplish the desired improvements that have been sought after. Adjuvant therapy, has offered little to the overall survival. The concept of early detection is now recognized as the initial step in reaching proper end results and can readily be demonstrated from colorectal cancer studies. Here survival has been found to be a reflection of the stage at which the tumor is first identified and treated. When specific monoclonals targeting colorectal cancer are employed diagnostically, we have been able to demonstrate detection of colorectal cancer at its inception as a premalignant lesion, such that genotypic features can be identified before the phenotypic appearance of cancer can be noted.
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A prospective comparative study of blended and pure coagulation current in endoscopic mucosal resection of large sessile colorectal polyps. Surg Laparosc Endosc Percutan Tech 2014; 24:226-31. [PMID: 24887540 DOI: 10.1097/sle.0b013e31829ce99e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to compare pure coagulation and blended current in the resection of large colorectal sessile polyps (SPs). PATIENTS AND METHODS Between January 2009 and June 2012, 84 patients (45 men, 39 women; median age 66 y; range, 42 to 88 y) with large colorectal SPs (diameter ≥2 cm) were randomized in 1:1 ratio to undergo treatment by the "lift and cut" piecemeal resection technique. A total of 43 blended current subjects (group A) were well matched to 41 pure coagulation current subjects (group B), with a median lesion size of 3.9 cm (group A, 3.7 vs. group B, 4.2 cm; P=0.316), respectively. The rate of complications, the factors that predict complications, and the recurrence of adenoma were analyzed. RESULTS Complete macroscopic resection was achieved in 39 patients (90.7%) of group A and in 36 patients (87.6%) of group B (P=0.735). Argon plasma coagulation at resection's margins was performed in 10 patients (23.2%) of group A and in 14 patients (34.1%) of group B (P=0.269). Eight patients (9.5%) [group A, n=3 patients (7.1%) vs. group B, n=5 patients (12%); P=0.756] developed immediate (4) or delayed (4) bleeding. Four patients with bleeding were under treatment with selective serotonin reuptake inhibitors. All bleedings were successfully treated conservatively or with endoclipping and heater probe application. Perforation occurred in 1 patient of each group and was managed by clips closure and antibiotics and right hemicolectomy, respectively. Postpolypectomy syndrome was observed in 2 patients (4.6%) of group A and 3 patients (7.3%) of group B (P=0.834). In 3 patients, the histopathologic analysis of resected SPs revealed invasive carcinoma, and surgical resection was performed in 1 patient. Two patients refused operation. Among the patients who underwent follow-up surveillance colonoscopy, a total recurrence rate of 25.67% of adenomas with no difference was observed between the 2 groups [group A, n=8 patients (21.6%) vs. group B, n=11 patients (31.4%); P=0.345]. Recurrence of adenoma was observed in 12 patients (16.22%) without and in 7 patients (9.46%) with argon plasma coagulation treatment. CONCLUSIONS No difference was found in the rate of complications between the 2 types of current used in the resection of large colorectal SPs. However, an influence of selective serotonin reuptake inhibitors on postpolypectomy bleeding was observed, which deserves further investigation.
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Albuquerque W, Arantes VN, Coelho LGV, Dias CAF, Savassi-Rocha PR. Complementation by argon plasma coagulation after endoscopic piecemeal resection of large colorectal adenomas. Rev Col Bras Cir 2014; 40:404-8. [PMID: 24573590 DOI: 10.1590/s0100-69912013000500010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 11/07/2012] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of complement by argon plasma coagulation to reduce the rate of residual or recurrent tumor after complete endoscopic piecemeal resection of large sessile colorectal adenomas. METHODS INCLUSION CRITERIA patients with large sessile colorectal adenomas (e" 20 mm), without morphological signs of deep infiltration, submitted to complete endoscopic piecemeal resection studied with chromoendoscopy and magnification of images. Patients were randomized into two groups: group 1 - no additional procedure, and group 2 - complementation by argon plasma coagulation. follow-up colonoscopy was performed at three, six and 12 months postoperatively. We evaluated the rate of local recurrence or residual malignancy. RESULTS The study included 21 patients, eleven in group 1 and ten in group 2. There were two local recurrences or residual tumors in each group, detected at three months follow-up. CONCLUSION Complementation by argon plasma coagulation after apparent complete endoscopic piecemeal resection of large sessile colorectal adenomas does not seem to reduce the occurrence of residual adenomatous lesions or local recurrence.
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Knabe M, Pohl J, Gerges C, Ell C, Neuhaus H, Schumacher B. Standardized long-term follow-up after endoscopic resection of large, nonpedunculated colorectal lesions: a prospective two-center study. Am J Gastroenterol 2014; 109:183-9. [PMID: 24343549 DOI: 10.1038/ajg.2013.419] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 10/08/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic removal of large, nonpedunculated colorectal lesions is challenging. Long-term outcome data based on standardized protocols, including detailed inspection of the resection site, are scarce. The aims of the present study were to evaluate the safety and efficacy of endoscopic resection (ER) of large, nonpedunculated lesions (LNLs; >20 mm) and to assess the long-term recurrence rate afterward. METHODS A total of 243 consecutive patients (141 men, 102 women) with 252 adenomas (>20 mm) was followed up using a standardized protocol after complete ER. After endoscopic treatment, the patients received standardized follow-up examinations after 3-6 months and 12 months. The postpolypectomy scar was re-examined, assessed for residual neoplasia, and biopsied at each follow-up colonoscopy. RESULTS Evident residual neoplasia was noted after 3-6 months in 58 of 183 lesions (31.69%). After 12 months, 126 LNLs were examined, with 19 late recurrences (16.37%). Twenty-one (6.5%) postpolypectomy scars were not detected during 321 surveillance examinations. Biopsy evidence of residual/recurrent lesions was found in 16 of 228 macroscopically inconspicuous polypectomy scars (7%). All residual adenomas were treated using ER and/or argon plasma coagulation. There were 43 complications with the 252 lesions (17%), including 20 major complications (7.9%), all managed conservatively. CONCLUSIONS A detailed study design with systematic biopsies of inconspicuous scars reveals a significant number of residual adenomas after completed resection. However, these residual neoplasias can be effectively treated at follow-up colonoscopies.
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Affiliation(s)
- Mate Knabe
- Department of Internal Medicine II, HSK Wiesbaden (Teaching Hospital of the University of Mainz), Wiesbaden, Germany
| | - Jürgen Pohl
- 1] Department of Internal Medicine II, HSK Wiesbaden (Teaching Hospital of the University of Mainz), Wiesbaden, Germany [2] Department of Internal Medicine, Vivantes-Klinikum, Friedrichshain, Berlin, Germany
| | - Christian Gerges
- Department of Internal Medicine II, Evangelisches Krankenhaus (Teaching Hospital of the University of Düsseldorf), Düsseldorf, Germany
| | - Christian Ell
- Department of Internal Medicine II, HSK Wiesbaden (Teaching Hospital of the University of Mainz), Wiesbaden, Germany
| | - Horst Neuhaus
- Department of Internal Medicine II, Evangelisches Krankenhaus (Teaching Hospital of the University of Düsseldorf), Düsseldorf, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine II, Evangelisches Krankenhaus (Teaching Hospital of the University of Düsseldorf), Düsseldorf, Germany
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Kim MS, Kim NK, Park JH. Intramural recurrence without mucosal lesions after an endoscopic mucosal resection for early colorectal cancer. Ann Coloproctol 2013; 29:126-9. [PMID: 23862131 PMCID: PMC3710774 DOI: 10.3393/ac.2013.29.3.126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/25/2013] [Indexed: 12/28/2022] Open
Abstract
Advances in endoscopic instruments and techniques have enabled increased detection and removal of early colorectal cancer (ECC), which is defined as a tumor whose invasion is limited to the mucosa or submucosa. Some cases can be treated by endoscopic mucosal resection (EMR). However, local recurrence frequently occurs after an EMR for ECC. The recurrence pattern is usually intramural recurrence with a mucosal lesion at the EMR's site. We report the cases of two patients with intramural recurrence without mucosal lesions after an EMR for ECC. These cases indicate that a local recurrence after an EMR for ECC can appear as an intramural recurrence without mucosal lesions at a previous EMR site or another site, although this presentation is very unusual.
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Affiliation(s)
- Min Sung Kim
- Department of Surgery, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
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44
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Local residual neoplasia after endoscopic treatment of laterally spreading tumors during 15 months of follow-up. Eur J Gastroenterol Hepatol 2013; 25:733-8. [PMID: 23442418 DOI: 10.1097/meg.0b013e32835eda96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Among superficial neoplastic lesions of the colon and rectum, a laterally spreading tumor (LST) is a flat elevated type at least 10 mm in size. It can be treated by conventional endoscopic resection (CER). Nevertheless, local residual neoplasia (LRN) may occur during follow-up. The aim of this prospective study was to evaluate the occurrence of LRN and the risk factors for its presence. METHODS Consecutive patients referred for CER of an LST were included. Follow-up colonoscopies were performed after 3 and 15 months. LRN was defined histologically as the presence of neoplastic tissue in the post-CER site. RESULTS Of a total of 127 patients with 127 lesions, follow-up could not be completed in 48 (37.8%). Of the remaining 79 (62.2%) patients (64.6% men, mean age 66.1±9.7 years), 63 (79.7%) were negative and 16 (20.3%) were positive for the presence of LRN after 15 months. Of 62 (78.5%) patients without LRN after 3 months, 55 (88.7%) remained negative after 15 months. Of 17 (21.5%) patients with LRN after 3 months, eight (47.1%) were negative after 15 months. In a multivariate analysis, LST size of at least 20 mm was found to be a significant risk factor after 3 months (odds ratio, 5.837; 95% confidence interval 1.199-28.425; P=0.029). After 15 months, the only significant risk factor was the presence of LRN observed after 3 months (odds ratio, 6.0; 95% confidence interval, 1.793-20.073; P=0.004). CONCLUSION This prospective study shows that the occurrence of LRN is frequent and its treatment is less effective than reported previously. These are important limitations of CER and should be taken into consideration for the management of patients with LSTs.
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45
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Endoscopic mucosal resection of giant laterally spreading tumors with submucosal injection of hydroxyethyl starch: comparative study with normal saline solution. Surg Laparosc Endosc Percutan Tech 2012; 22:272-8. [PMID: 22678327 DOI: 10.1097/sle.0b013e318251553c] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cushion for a safe and effective endoscopic mucosal resection (EMR) of sessile colorectal polyps. It was hypothesized that hydroxyethyl starch (HES), an inexpensive and easily available solution might be an ideal solution for prolonged elevation of submucosal cushion for an easy and safe EMR of giant colorectal lateral spreading tumors (LSTs). PATIENTS AND METHODS During a 6-year period, patients suffering from colorectal LSTs with a diameter of ≥ 30 mm were randomized to undergo EMR by using either HES+E (group A) or NS+E (group B) for submucosal fluid cushion. All patients who had undergone a colonoscopy set the diagnosis of LSTs. The LSTs were examined with standard white light and narrow-band imaging to accurately delinate their margins before resection. The initial volume of injected solution, the additional amount to maintain the submucosal cushion, the duration of submucosal elevation and post-EMR-related complications were recorded. After EMR, patients had a standard follow-up at 3, 6, and 12 months and further if it was necessary using total colonoscopy. RESULTS Forty-nine patients suffering from giant LSTs were included in the study. No difference between the 2 groups was observed in patients' characteristics, size of LSTs, and the initial volume of injected solution. However, the additional amount of solution to maintain submucosal elevation was lower in group A (median, 4 mL; range, 2 to 25) than in group B (median, 6 mL; range, 3 to 8; P=0.001). Moreover, submucosal elevation had a statistically longer duration in group A (median, 18.5 min; range, 14.5 to 28.4) than in group B (median, 20.15 min, range, 9.6 to 13.4; P<0.001), and there was a statistical difference on total procedure time in favor of group A [group A, 20.15 min (12 to 32.5) vs. group B, 22.8 min (18 to 34.5)]. One case of macroperforation, 2 cases of postpolypectomy syndrome, and 1 case of EMR-related bleeding were observed in the HES+E group, whereas 6 cases of EMR-related bleeding were observed in the NS+E group. During a median follow-up of 32 and 34 months, for HES+E and NS+E groups, respectively, 5 and 7 recurrences were observed, which were all treated endoscopically. CONCLUSIONS HES+E injection produces a more prolonged submucosal elevation and lowers total procedure time than NS+E; however, the safety of EMR is not influenced.
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Barendse RM, van den Broek FJC, van Schooten J, Bemelman WA, Fockens P, de Graaf EJR, Dekker E. Endoscopic mucosal resection vs transanal endoscopic microsurgery for the treatment of large rectal adenomas. Colorectal Dis 2012; 14:e191-6. [PMID: 22023493 DOI: 10.1111/j.1463-1318.2011.02863.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM Large (> 2 cm) rectal adenomas are currently treated by transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR becomes irrelevant if it is less effective. We aimed to compare the safety and effectiveness of EMR and TEM for large rectal adenomas. METHOD Data from patients undergoing TEM or EMR for a rectal adenoma > 2 cm in eight hospitals were retrospectively collected. Patient- and procedure-related characteristics, complications and recurrences were recorded. As EMR may require several attempts to achieve complete resection, early (after a single intervention) and late (permitting re-treatment for residual adenoma within 6 months) recurrence rates were determined. RESULTS Two hundred and ninety-two (292) patients (49% male; mean age 67 years) were included; 219 were treated by TEM and 73 by EMR. Adenomas treated by EMR were smaller (median 30 vs 40 mm; P = 0.007). Perioperative complication rates were 2% for TEM and 6% for EMR (P = 0.171). Postoperative complications occurred in 24% of TEM patients and in 13% of EMR patients (P = 0.038). Median hospitalization after TEM was 3 days vs 0 days after EMR (P < 0.001). Median follow-up was 12.6 months (0-47 months); Early recurrence rates were 10.2% in TEM patients and 31.0% in EMR patients (P < 0.001); late recurrence rates were 9.6% and 13.8%, respectively (P = 0.386). CONCLUSION After a single intervention, EMR of large rectal adenomas seems less effective, but safer than TEM. When allowing re-treatment of residual adenoma within 6 months, EMR and TEM seem equally effective. A prospective randomized comparison seems to be necessary.
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Affiliation(s)
- R M Barendse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands.
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Terasaki M, Tanaka S, Oka S, Nakadoi K, Takata S, Kanao H, Yoshida S, Chayama K. Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm. J Gastroenterol Hepatol 2012; 27:734-40. [PMID: 22098630 DOI: 10.1111/j.1440-1746.2011.06977.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Colorectal laterally spreading tumors (LST) > 20 mm are usually treated by endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR). Endoscopic piecemeal mucosal resection (EPMR) is sometimes required. The aim of our study was to compare the outcomes of ESD and EMR, including EPMR, for such LST. METHODS A total of 269 consecutive patients with a colorectal LST > 20 mm were treated endoscopically at our hospital from April 2006 to December 2009. We retrospectively evaluated the complications and local recurrence rates associated with ESD, hybrid ESD (ESD with EMR), EMR, and EPMR. RESULTS ESD and EMR were performed successfully for 89 and 178 LST, respectively: 61 by ESD; 28 by hybrid ESD; 70 by EMR; and 108 by EPMR. Between-group differences in perforation rates were not significant. Local recurrence rates in cases with curative resection were as follows: 0% (0/56) in ESD; 0% (0/27) in hybrid ESD; 1.4% (1/69) in EMR; and 12.1% (13/107) in EPMR; that is, significantly higher in EPMR. No metastasis was seen at follow up. The recurrence rate for EPMR yielding ≥ three pieces was significantly high (P < 0.001). All 14 local recurrent lesions were adenomas that were cured endoscopically. CONCLUSIONS As for safety, ESD/hybrid ESD is equivalent to EMR/EPMR. ESD/hybrid ESD is a feasible technique for en bloc resection and showed no local recurrence. Although local recurrences associated with EMR/EPMR were seen, which were conducted based on our indication criteria, all local recurrences could obtain complete cure by additional endoscopic treatment.
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Affiliation(s)
- Motomi Terasaki
- Department of Gastroenterology and Metabolism, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
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Baretton GB, Tannapfel A, Schmitt W. [Standardized and structured histopathological evaluation of colorectal polyps: a practical checklist against the background of the new WHO classification]. DER PATHOLOGE 2012; 32:289-96. [PMID: 21678043 DOI: 10.1007/s00292-011-1436-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Gastroenterologists removing colorectal polyps expect standardized and well-structured pathological reports, providing them with all relevant data for the further clinical management of the patient. Over the last year, a task force of clinicians and pathologists has developed a checklist to improve and harmonize endoscopic and pathological reporting of colorectal polyps. This checklist concentrates more on concrete recommendations from evidence-based guidelines and established international classifications for daily practice rather than detailed molecular pathological pathways of carcinogenesis. These recommendations are based on the current S3 guidelines for colorectal cancer (the chapter entitled "Management of colorectal polyps"), the histomorphological consensus manuscript of the GI working group of the German Society for Pathology, as well as the current WHO classification for tumors of the digestive system.
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Affiliation(s)
- G B Baretton
- Institut für Pathologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
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Raju GS, Saito Y, Matsuda T, Kaltenbach T, Soetikno R. Endoscopic management of colonoscopic perforations (with videos). Gastrointest Endosc 2011; 74:1380-8. [PMID: 22136781 DOI: 10.1016/j.gie.2011.08.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/04/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Azzolini F, Camellini L, Sassatelli R, Sereni G, Biolchini F, Decembrino F, De Marco L, Iori V, Tioli C, Cavina M, Bedogni G. Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps). Clin Res Hepatol Gastroenterol 2011; 35:572-9. [PMID: 21640691 DOI: 10.1016/j.clinre.2011.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 04/06/2011] [Accepted: 04/14/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS Endoscopic submucosal dissection (ESD) was developed for en bloc resection of superficial neoplasm of the digestive tract. We evaluated feasibility and safety of ESD, as a salvage therapy of large refractory rectal polyps, in a tertiary care setting. METHODS We prospectively enrolled in the present study and treated by ESD 11 consecutive patients with rectal polyps (median diameter 3.5 cm; range 2-5 cm), who had previously undergone several attempts of endoscopic resection and not suitable for further standard endoscopic treatment. The ESD was carried out with a standard needle knife. Follow up examinations were scheduled at 3, 6, 12 and 24 months. RESULTS We achieved apparently complete resection of polyps in 10/11 patients. In one patient ESD was interrupted and the pathology of the resected fragment showed deep submucosal infiltration; this patient underwent surgery. Deep and lateral margins were shown to be free of neoplasm (radical resection) in six out of 11 patients. However all the 10 patients with apparently complete resection were free of recurrence after a mean follow up of 19.2 months (12-24). A T1 adenocarcinoma was radically resected by ESD, with no recurrence. We recorded 2 cases of subcutaneous emphysema, both treated conservatively. CONCLUSIONS Radical resection is difficult to be achieved by ESD in patients with rectal scar-embedded polyps. Nevertheless ESD may be proposed as a definitive treatment of selected patients with refractory polyps, avoiding surgery in the majority of them.
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Affiliation(s)
- F Azzolini
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria, Viale Risorgimento 80, 42100 Reggio Emilia, Italy.
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