Endoscopic Submucosal Dissection (ESD) for Large Colorectal Tumors Comparing with Endoscopic Piecemeal Mucosal Resection (EPMR)

Abstract

Introduction: Endoscopic submucosal dissection (ESD) is defined as an en bloc resection method without dividing tumor. We have performed ESD for large colorectal tumors successfully. We report our en bloc resection technique for colorectal tumors comparing with endoscopic mucosal resection (EMR) and endoscopic piecemeal mucosal resection (EPMR). Patients and Methods; ESD were performed in 322 patients under conscious sedation treatment with 341 GI lesions (esophagus: 36 lesions, stomach: 185 lesions, duodenum: 1 lesion, colon and rectum: 119 lesions) Among these patients, 119 colorectal tumors (adenomas and early cancers) from 116 patients (69 male, 46 female, mean age was 66.1 years old) were resected en-blocky by ESD. In this study, we examined (1) the size of the lesions, the time required to achieve this procedure, and complication between each organs, (2) the clinico-pathological findings of colorectal tumors, (3) the prognosis of ESD comparing with EMR and piecemeal EMR (EPMR). The indications of ESD are as follows. First, the tumor larger than 2 cm in diameter. Second, the pit pattern of the tumor is type IIIL, IIIS, IV or VI (mucosal or minimally submucosal invasive cancer). Third, the tumor without VN pit pattern or non-lifting sign. Results: The average size and operating time were 30.4 mm(13-80 mm) and 53.3 minutes(7-200). We experienced 1 case (0.8%) with micro-perforation, and this case was healed by clipping. The tumor locations were as follows: 14 lesions from caecum, 181 from ascending colon, 17 from transverse colon, 5 from descending colon, 44 from sigmoid colon and 21 from rectum . Macroscopic findings were 85 with laterally spreading tumor, 31 with protruded type and 2 with depressed type. Histopathological findings showed 36 as adenoma, 66 as intramucosal cancer (category 5-1 of Vienna Classification), 16 as submucosal cancer (category 5-2), and 1 lesion as submucosal tumor (lipoma with 8 cm in diameter). All cases were followed up at least 3 months after resection by colonoscopic examinations. Neither residual tumor nor recurrence was seen. Contrarily three cases (6.5%) with recurrence tumor were reported in piecemeal EMR (EPMR) from 46 cases (larger than 2 cm in diameter), which were followed over one year. One complication case with perforation (0.8%) was discovered in ESD, which used conservative closing treatment by endoclips.. Conclusion: The safety of ESD for colorectal tumor has been built up gradually. With the development of the device and the technique for ESD, ESD might be performed more safely in the near future. ESD will play an important role in the therapeutic strategy for colorectal tumors.