Mo1745 ENDOSCOPIC SUBMUCOSAL DISSECTION IN IBD ASSOCIATED DYSPLASIA: A SYSTEMATIC REVIEW

Abstract

Guidelines for management of IBD associated dyplasia are evolving but 2015 consensus guidelines recommend surveillance over colectomy for patients with complete endoscopic removal of dysplastic lesions. 2019 guidelines from the American college of gastroenterology also support complete endoscopic removal of dysplastic lesions as an alternative to colectomy. Critically, confirmation of complete removal can be challenging with lesions that are large or fibrotic requiring piecemeal resection. Endoscopic submucosal dissection offers improved rates of en-bloc resection compared to endoscopic mucosal resection and may be the optimal technique for resection of large or fibrotic IBD-associated dysplastic lesions. An electronic search of EMBASE (1974–present), MEDLINE (1946–present), EBM Reviews– Cochrane Central Register of Controlled Trials (1946–present), EBM Reviews–Cochrane Database of Systematic Reviews (2005–present), and Google Scholar was conducted for studies reporting outcomes of endoscopic resection of large dysplastic lesions in IBD. Bibliographies of retrieved articles were also reviewed for relevant publications. Outcomes were extracted and pooled for comparison across techniques. Two tailed p-values were calculated using fishers exact test. 195 articles were identified on initial search. 154 were excluded based on review of title. 41 papers were reviewed in full. Case-reports, review articles and consensus statements were excluded. 8 individual case series and cohort studies were identified. In total, 295 unique patients and 322 unique lesions were identified. 122 (41%) patients were male, 95% had ulcerative colitis, 4% Crohn’s and 1% were undifferentiated. 166 lesions were removed by EMR, 116 via ESD and 30 using hybrid techniques. 10 lesions were managed with colectomy. A significantly higher proportion of lesions excised by ESD compared to EMR/hybrid were fibrotic (91.5% vs 7.7%, p<.00001) and non-polypoid (82% vs 60%, p<.008). Lesion size was not consistently reported and could not be pooled. Endoscopic recurrence did not differ between ESD and EMR/hybrid (8.6% vs 4.6%, p<.219). ESD had a significantly higher en-bloc resection rate (92% vs 78%, p<.005). Overall complication rates did not differ significantly (ESD 6% vs EMR 2% p<.097, ESD 6% vs hybrid 6.6% p<1). Published reports of endoscopic resection and specifically ESD for IBD associated dysplasia show favourable outcomes as measured by complete resection, low recurrence and acceptable complication rates. ESD has higher en-bloc resection rates compared to EMR, with no significant difference in endoscopic recurrence or complications. Interpretation of comparisons between EMR and ESD is likely biased by tendency to use ESD for flatter and more fibrotic lesions.