Comparison of the Performance Characteristics of Endoscopic Submucosal Dissection with Laparoscopic Assisted Colectomy for En-Bloc Resection of Colorectal Neoplasm

Abstract

Background: Laparoscopic assisted colectomy (LAC) has become an accepted minimally-invasive alternative to open surgery for the resection of colorectal neoplasm. Endoscopic submucosal dissection (ESD) has recently become an additional alternative, but is reportedly associated with a steep learning curve and significant risk of complications. Aim: The indication for ESD in our hospital is intramucosal or sm1 lesion, and that for LAC is sm2 or deeper cancer. However, the standard treatment for large colorectal adenoma or intramucosal lesions in many hospitals worldwide is LAC. We therefore compared ESD in the treatment of colorectal neoplasm with LAC used to resect colorectal carcinoma. Methods: The subjects had early stage colorectal tumors of preoperative T1 or less (LAC), or colorectal adenoma/ Tis (intramucosal) and sm1 (less than 1000μm) carcinoma (ESD) from February 1998 to October 2007. We assessed clinical results and complications in both groups. Result: There were 300 cases in the ESD group, and 272 cases in LAC. There was no difference between the 2 groups in terms of age and gender. The cases, stratified by depth of invasion (if carcinoma), were as follows: m/sm1/sm2-/mp/ss were 152/35/36/2/0 in ESD, and 43/20/197/10/1 in LAC groups. In the ESD cases, the mean tumor size was 36 mm (7-140). The en-bloc resection rate and curative resection rates were 86% and 83% respectively. The average time of procedure was 109 mins (15-480). There were 12 cases complicated by perforation (4%) and 4 with post-procedure bleeding (1.3%) among the ESD patients. All complications were managed endoscopically except for one patient with perforation. In the LAC group, the mean tumor size was 19 mm (3-80). The average time of operation was 210 mins (95-500). There were 31 wound infections, 2 pelvic abscesses, 3 anastomotic leaks and 1 patient with anastomotic bleeding. Stomas were necessary in 75% cases in LAC of rectal lesions below the peritoneal reflection (11 temporary ileostomies and 1 permanent colostomy). No blood transfusions were required for either ESD or LAC cases. Conclusion: In this series, ESD was associated with few complications and a high rate of en-bloc resection when used to treat superficial colorectal neoplastic lesions including a significant number of early carcinomas. Its safety profile and en-bloc resection rate were favourable when compared with LAC. ESD represents a promising minimally-invasive therapy for superficial colorectal carcinoma; randomized studies and outcome studies are needed.