Colorectal endoscopic submucosal dissection from a Western perspective: Today’s promises and future challenges

Table 1 Indications for colorectal endoscopic submucosal dissection (Japan Gastroenterological Endoscopy Society)

Lesions for which endoscopic en bloc resection is required

(1) Lesions for which en bloc resection with snare EMR is difficult to apply

LST-NG, particularly LST-NG pseudo-depressed type

Lesions showing a Vi-type pit pattern

Carcinoma with shallow T1 submucosal invasion

Large depressed-type tumors

Large protruded-type lesions suspected to be carcinoma. Including LST- G, nodular mixed type

(2) Mucosal tumors with submucosal fibrosis as a result of a previous biopsy or prolapse caused by intestinal peristalsis

(3) Sporadic localized tumors in conditions of chronic inflammation such as ulcerative colitis

(4) Local residual or recurrent early carcinomas after endoscopic resection

EMR: Endoscopic mucosal resection; LST-NG: Laterally spreading tumor non granular; LST-G: Laterally spreading tumor granular.

Table 2 Colorectal endoscopic submucosal dissection outcomes for epithelial neoplasms in Asian studies

Ref.	Patients, n(% rectal)	Study design	Enrollmentperiod	Size(mm)	Time(min)	En bloc(%)	R0(%)	Perforationrate(%)	Delayedbleeding(%)	Hospitalstay(d)	Follow-up
Fujishiro et al[63], 2006	35 (100)	Prospective	Feb 2001 Feb 2005	32.8	NS	88.6	62.9	5.7	28.6	-	Missing rate: n = 0; 0% Mean: 36 mo (12-60) Recurrence rate at 2 mo: 2.8% 31/32 (96.8%) recurrence-free at 3 yr
Tamegai et al[64], 2007	71 (23.9)	NS	Jan 2003 Dec 2005	32.7	61.1	98.6	95.6	NS	1.4	-	Missing rate: n = 7; 9.86% Mean: 12.2 mo (range 3-34) Recurrences: 0%
Hurlstone et al[70], 2007	42 (33.3)	Prospective	Mar 2004 Aug 2006	31	48	78.6	73.8	2.4	2.4	22	Missing rate: n = 6; 14.3% Median: 6 mo (range: 3-18) Recurrences 4/36 (11%) Curative resections at 6 mo: 34/42 (81%)
Fujishiro et al[112], 2007	200 (26)	NS	Jul 2000 Mar 2006	29.9	-	91.5	70.5	6	0.5	-	Median: 18 mo (range 12-60) Recurrences: 1.8%
Saito et al[65], 2007	200 (30.5)	NS	Oct 2003 Jul 2006	35	90	84	70	5	2	5	Median: 7 mo Missing rate: 10% Recurrences: 0.5%
Tanaka et al[68], 2007	70 (48.6)	NS	< Dec 2005	28	70.5	80	-	10	1.4	-	In curative resections, 0% recurrence rate Other information not provided
Zhou et al[113], 2009	74 (56.7)	NS	Jul 2006 Dec 2007	32.6	110	93.2	89.2	8.1	1.4	-	Missing rate: n = 0; 0% Median: 14.3 mo (range 3-22) Recurrences: 0%
Isomoto et al[114], 2009	292 (26.7)	NS	May 2001 Dec 2008	26.8	-	90.1	79.8	7.9	0.7	-	Missing rate: 24.6% Median: 33 mo in R0 36 mo in non-R0 resections R0: 0% recurrences 1 recurrence in non-R0 resections
Saito et al[115], 2009	405 (27.4)	NS	NS	40	90	86.9	-	3.5	1	-	Mean ± SD: 20 ± 13 mo 2% recurrences
Iizuka et al[62], 2009	44 (59)	Retrospective	Jan 2000 Dec 2004	39	110	61	58	8	-	-	-
Niimi et al[60], 2010	310 (26.1)	Retrospective Monocentric	Jul 2000 Dec 2008	28.9	-	90.3	74.5	4.8	1.3	-	Median: 38.7 mo (12.8-104.2) 2% recurrences 3-yr overall/disease-specific survivals: 97.1%/100% 5-yr overall/disease-specific survivals: 95.3%/100% 8 died of other coexisting diseases 0 died of CRC
Yoshida et al[116], 2010	250 (31.6)	NS	Apr 2005 Mar 2010	29.6	106	86.8	81.2	6	2.4	-	-
Saito et al[81], 2010	145 (50.3)	Retrospective	Jan 2003 Dec 2006	37	108	84	-	6.2	1.4	-	Median: 20 mo 2.1% recurrences
Hotta et al[38], 2010	120 (27.5)	NS	Jun 2003 Sep 2008	> 30	141	93.3	85	7.5	-	-	-
Saito et al[12], 2010	1111 (30.3)	Multicentric Prospective	Jun 1998 Feb 2008	35	116	88	89	5.3	1.5	-	-
Toyonaga et al[117], 2010	268 (25.7)	Retrospective	May 2002 May 2007	40.3	64.5	99.2	98.1	2.2	0.37	-	Median: 32.2 mo (6.5-85.2) Follow-up: 227 out of the 241 curative resections (94.2%) Missing rate: 5.8% Recurrences: 0%
Matsumoto et al[118], 2010	203 (NS)	NS	Nov 2002 Jun 2009	33	-	85.7	-	6.9	-	-	-
Uraoka et al[119], 2011	202 (32.7)	NS	Apr 2006 Mar 2010	40	-	91.6	87.1	2.4	0.5	-	Median: 11.4 mo Missing rate: 14% 0% disease specific mortality 1.5% overall mortality
Shono et al[61], 2011	137 (26.2)	NS	Apr 2007 Oct 2010	29.2	79.2	89.1	85.4	3.6	3.6	-	0% recurrences No other information provided
Kim et al[120], 2011	108 (44)	Retrospective	Mar 2007 Feb 2009	27.6	61.9	-	78.7	20.4	-	-	-
Lee et al[84], 2012	314 (19.1)	Retrospective	Jan 2004 Nov 2009	28.9	54.7	92.7	87.6	8	0.64	3.6	-
Lee et al[121], 2012	499 (18.1)	Retrospective	Oct 2006 Nov 2010	28.9	61.3	95	-	7.4	-	3.6	-
Hisabe et al[122], 2012	200 (30)	NS	Jun 2003 Jun 2011	32.7	108.9	86	-	7	1	-	-
Saito et al[123], 2012	1321 (25.6)	Multicentric	-	34.2	90	95.4	87.2	2.9	2.5	-	-
Okamoto et al[71], 2013	30 (50)	NS	Dec 2010 Aug 2012	36	61	-	100	0	0	-	-
Lee et al[72], 2013	874 (20.7)	Retrospective	> Oct 2006	26.5	53.8	97.1	90.5	6.1	0.5	3.5	-
Nakajima et al[80], 2013	816 (36.3)	Prospective Multicentric	Oct 2007 Dec 2010	39.4	96	94.5	90.6	2	2.2	-	-
Nawata et al[124], 2014	150 (20.6)	Retrospective 2 groups: A < 50 mm/B ≥ 50 mm	Apr 2010 Jul 2013	26/59	38/86	98.7	97.3	0	0	-	-
Sakamoto et al[66], 2014	164 (38)	Retrospective	Apr 2005 Mar 2012	30	95	95	92	4	3	-	-
Saito et al[109], 2014	900 (NS)	NS	NS	40	100	91	87	2.7	1.7	-	-
Lee et al[125], 2015	173 (24.3)	Retrospective	Jan 2010 Dec 2013	25.95	-	88.4	81.5	11	3.4	-	-
Rahmi et al[67], 2015	28 (25)	Retrospective 100% recurrences	Dec 2008 Jul 2013	17.5	63	96.4	92.9	3.5	0	7	Median: 22 mo Missing rate: 35.7% Recurrences: 0%

The given values for the size of the lesion and time spent on the procedure are shown as the measure of central tendency reported in the study (mean or median as appropriate). NS: Not specified. -: Information is not mentioned in the original paper.

Table 3 Colorectal endoscopic submucosal dissection outcomes for epithelial neoplasms in European studies

Ref.	Patients, n (% rectal)	Study design	Enrollment period	Size (mm)	Time (min)	En bloc (%)	R0 (%)	Perforation rate (%)	Delayed bleeding (%)	Hospital stay (d)	Follow-up
Farhat et al[16], 2011	85 (84.7)	Prospective	Jan 2008 Aug 2010	-	-	67	62.3	-	-	-	-
Probst et al[14], 2012	76 (86.6)	NS	Oct 2004 Sep 2011	45.8	176	81.6	69.7	6.6	10.5	-	Median: 23.6 mo (2-83) Included in follow-up: n = 65 9.2% residual neoplasms (5 piecemeal and 1 en bloc R1 lateral)
Repici et al[20], 2013	40 (100)	Prospective	Apr 2010 Jan 2011	46.8	86.1	90	80	5	2.5	-	Recurrences: 2.5%
Thorlacius et al[126], 2013	29 (59)	NS	Jan 2012 Mar 2013	28	142	72	69	6.9	0	-	Recurrences: 0% at 3-6 mo Missing rate: 82.7%
Spychalski et al[127], 2015	70 (56)	NS	Jun 2013 Jun 2014	30	110	66	-	8	6	-	Missing rate: 14.6% Recurrences: 4.9% Follow-up < 12 mo
Rahmi et al[128], 2014	45 (100)	NS	Feb 2010 Jun 2012	35	110	64	53	18	13	3.4	For curative resections at 12 mo: 88%
Bialek et al[129], 2014	37 (67.6)	Prospective	2007 2013	37	70	86.5	81.1	0	5.7	-	At 1-yr follow-up: 1.7% recurrences

The given values for the size of the lesion and the time spent on the procedure are shown as the measure of central tendency reported in the study (mean or median as appropriate). NS: Not specified. -: Information is not mentioned in the original paper.