Retrospective Cohort Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jun 16, 2023; 15(6): 458-468
Published online Jun 16, 2023. doi: 10.4253/wjge.v15.i6.458
Multicenter evaluation of recurrence in endoscopic submucosal dissection and endoscopic mucosal resection in the colon: A Western perspective
Mike T Wei, Margaret J Zhou, Andrew A Li, Andrew Ofosu, Joo Ha Hwang, Shai Friedland
Mike T Wei, Margaret J Zhou, Andrew A Li, Joo Ha Hwang, Shai Friedland, Department of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA 94306, United States
Andrew Ofosu, Department of Gastroenterology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
Author contributions: Wei MT contributed to project conception, data collection, manuscript writing, data analysis, manuscript revision; Zhou MJ, Li AA and Ofosu A contributed to data analysis, manuscript revision; Hwang JH and Friedland S contributed to project conception, data collection, manuscript revision.
Institutional review board statement: This study was performed under the approval of the Institutional Review Board at Stanford University, Stanford, California, USA.
Informed consent statement: Because of retrospective study signed informed consent form is not needed.
Conflict-of-interest statement: Mike T. Wei: Consultant for Neptune Medical, AgilTx, Capsovision; Margaret Zhou and Andrew Ofosu: No conflicts; Andrew Li: Consultant for Neptune Medical; Joo Ha Hwang: Consultant for Olympus, Medtronic, Boston Scientific, Lumendi, Fujifilm, Noah Medical, Neptune Medical, and Micro-Tech; Shai Friedland: Consultant for Intuitive Surgical and Capsovision.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mike T Wei, MD, Clinical Assistant Professor, Department of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA 94306, United States. mtwei@stanford.edu
Received: February 20, 2023
Peer-review started: February 20, 2023
First decision: April 13, 2023
Revised: May 12, 2023
Accepted: May 31, 2023
Article in press: May 31, 2023
Published online: June 16, 2023
Abstract
BACKGROUND

While colon endoscopic mucosal resection (EMR) is an effective technique, removal of larger polyps often requires piecemeal resection, which can increase recurrence rates. Endoscopic submucosal dissection (ESD) in the colon offers the ability for en bloc resection and is well-described in Asia, but there are limited studies comparing ESD vs EMR in the West.

AIM

To evaluate different techniques in endoscopic resection of large polyps in the colon and to identify factors for recurrence.

METHODS

The study is a retrospective comparison of ESD, EMR and knife-assisted endoscopic resection performed at Stanford University Medical Center and Veterans Affairs Palo Alto Health Care System between 2016 and 2020. Knife-assisted endoscopic resection was defined as use of electrosurgical knife to facilitate snare resection, such as for circumferential incision. Patients ≥ 18 years of age undergoing colonoscopy with removal of polyp(s) ≥ 20 mm were included. The primary outcome was recurrence on follow-up.

RESULTS

A total of 376 patients and 428 polyps were included. Mean polyp size was greatest in the ESD group (35.8 mm), followed by knife-assisted endoscopic resection (33.3 mm) and EMR (30.5 mm) (P < 0.001). ESD achieved highest en bloc resection (90.4%) followed by knife-assisted endoscopic resection (31.1%) and EMR (20.2%) (P < 0.001). A total of 287 polyps had follow-up (67.1%). On follow-up analysis, recurrence rate was lowest in knife-assisted endoscopic resection (0.0%) and ESD (1.3%) and highest in EMR (12.9%) (P = 0.0017). En bloc polyp resection had significantly lower rate of recurrence (1.9%) compared to non-en bloc (12.0%, P = 0.003). On multivariate analysis, ESD (in comparison to EMR) adjusted for polyp size was found to significantly reduce risk of recurrence [adjusted hazard ratio 0.06 (95%CI: 0.01-0.57, P = 0.014)].

CONCLUSION

In our study, EMR had significantly higher recurrence compared to ESD and knife-assisted endoscopic resection. We found factors including resection by ESD, en bloc removal, and use of circumferential incision were associated with significantly decreased recurrence. While further studies are needed, we have demonstrated the efficacy of ESD in a Western population.

Keywords: Endoscopic mucosal resection, Endoscopic submucosal dissection, Recurrence, Colonoscopy, Polypectomy

Core Tip: Endoscopic submucosal dissection is an effective and safe technique. Compared to endoscopic mucosal resection, we find that endoscopic submucosal dissection as well as knife-assisted endoscopic resection to achieve higher en bloc resection, circumferential incision, R0 resection as well as lower recurrence rate. While further studies are needed, we have demonstrated the efficacy of endoscopic submucosal dissection in a Western population.