Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jul 25, 2015; 7(9): 881-888
Published online Jul 25, 2015. doi: 10.4253/wjge.v7.i9.881
For “difficult” benign colorectal lesions referred to surgical resection a second opinion by an experienced endoscopist is mandatory: A single centre experience
Carmelo Luigiano, Giuseppe Iabichino, Nico Pagano, Leonardo Henry Eusebi, Stefania Miraglia, Antonino Judica, Angela Alibrandi, Clara Virgilio
Carmelo Luigiano, Giuseppe Iabichino, Stefania Miraglia, Antonino Judica, Clara Virgilio, Unit of Gastroenterology and Digestive Endoscopy, ARNAS Garibaldi, 95122 Catania, Italy
Nico Pagano, Leonardo Henry Eusebi, Unit of Gastroenterology, S. Orsola-Malpighi University Hospital, 40138 Bologna, Italy
Angela Alibrandi, Department of Statistics, University of Messina, 98122 Messina, Italy
Author contributions: Luigiano C and Iabichino G designed research and wrote the text; Luigiano C performed the endoscopic resection; Iabichino G, Miraglia S and Judica A managed the medical record and extracted all the results from the endoscopy and surgical database for analysis; Pagano N and Eusebi LH were involved in editing the manuscript and literature research; Alibrandi A performed data analysis; Virgilio C reviewed the paper for important intellectual content.
Institutional review board statement: The study was a retrospective study and as such did not require review and approval by the Institutional Review board.
Informed consent statement: The study was a retrospective study using routinely collected hospital data, and as such did not require a specific informed consent.
Conflict-of-interest statement: Neither this submitted paper nor any similar paper, in whole or in part, has been or will be submitted to any other primary scientific journal. All authors have reviewed this manuscript and have agreed with the contents. There are no financial arrangements or commercial associations (e.g., equity ownership or interest, consultancy, patent and licensing agreement, or institutional and corporate associations) which might be a conflict of interest in relation to the manuscript submitted.
Data sharing statement: No additional data available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Carmelo Luigiano, MD, Unit of Gastroenterology and Digestive Endoscopy, ARNAS Garibaldi, Via Palermo 636, 95122 Catania, Italy. carmeluigiano@libero.it
Telephone: +39-9-57595408 Fax: +39-9-57595828
Received: April 5, 2015
Peer-review started: April 8, 2015
First decision: May 14, 2015
Revised: June 4, 2015
Accepted: June 30, 2015
Article in press: July 2, 2015
Published online: July 25, 2015
Abstract

AIM: To assess how many patients with benign “difficult” colorectal lesions (DCRLs) referred to surgical resection, may be treated with endoscopic resection (ER) rather than surgical resection.

METHODS: The prospectively collected colonoscopy database of our Endoscopic Unit was reviewed to identify all consecutive patients who, between July 2011 and August 2013, underwent an endoscopic re-evaluation before surgical resection due to the presence of DCRLs with a histological confirmation of benignancy on forceps biopsy. ER was attempted when the lesion did not have definite features of deeply invasive cancer. The “nonlifting sign” excluded ER only in naive lesions without a prior attempted resection. Lesions were classified, using the Kyoto-Paris classification for mucosal neoplasia. For sessile and non-polypoid lesions the “inject and cut” resection technique was used. Pedunculated and semi-pedunculated lesions were transected at the stalk just below the polyps head and before or after resection, metal clips or a loop were applied on the stalk to prevent bleeding. The lesions were histologically classified according to the Vienna criteria and for the pedunculated lesions the Haggitt classification was used.

RESULTS: Eighty-two patients (42 females, mean age 62 years) with 82 lesions (mean size 37 mm) were included in the study. Sixty-nine (84%) lesions were endoscopically resected, while 13 underwent surgical resection since ER was deemed unsuitable. On histology, cancer was found in 21/69 lesions (14 intra-mucosal, 7 sub-mucosal) and was associated with the size (P < 0.001) and with type 0-IIa +Is (P = 0.011) and 0-IIa + IIc (P < 0.001) lesions. All patients with sub-mucosal cancer, underwent surgical resection. Complications occurred in 11/69 patients (7 bleedings, 2 transmural burn syndromes, 2 perforations), all managed endoscopically or conservatively, and were associated with presence of invasive cancer (P = 0.021). During follow-up recurrence/residual tissue was found in 14/51 sessile or non-polypoid lesions (13 treated endoscopically, 1 underwent surgical resection) and was associated with type 0-IIa + Is lesions (P = 0.001), piecemeal resections (P = 0.01) and with lesion size (P = 0.004). Overall, 74% of patients avoided surgery. Surgical resection was significantly associated with type 0-IIa + Is (P = 0.01) and 0-IIa + IIc (P = 0.001) lesions, with sub-mucosal invasion on histology (P < 0.001), with presence of the “nonlifting sign” (P < 0.001), and related to the dimension of the lesions (P = 0.001). In the logistic regression analysis, the only independent predictor for surgical resection was the dimension of the lesions (P = 0.002).

CONCLUSION: Before submitting patients to surgical resection for a benign DCRL, a second opinion by an experienced endoscopist is mandatory to avoid unnecessary surgery.

Keywords: Difficult colorectal lesion, Complications, Endoscopic resection, Non-polypoid lesions, Polypoid lesions, Recurrence

Core tip: A “difficult” colorectal lesion (DCRL) is defined as any lesion that due to its size, shape and location or due to fibrosis as a consequence of previous attempts of endoscopic resection (ER), makes it difficult to remove. Patients with DCRLs are often referred to surgeons for surgical colorectal resection. In our institution, for all patients referred for colorectal surgical resection for DCRLs, the surgeons request an endoscopic re-evaluation and if possible an ER of the lesions. The purpose of this study was to review our results with this approach.