Early Colorectal Neoplasms Research Articles

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

Over the last few years, endoscopic submucosal dissection (ESD) has shown to be effective in the management of early colorectal neoplasms, particularly in Asian countries where the technique was born. In the Western world, its implementation has been slow and laborious. In this paper, the indications for ESD, its learning model, the available methods to predict the presence of deep submucosal invasion before the procedure and the published outcomes from Asia and Europe will be reviewed. Since ESD has several limitations in terms of learning achievement in the West, and completion of the procedure for the first cases is difficult in our part of the world, a short review on colorectal assisted ESD has been included. Finally, other endoscopic and surgical treatment modalities that are in competition with colorectal ESD will be summarized.

Serum miR-21, miR-29a, and miR-125b Are Promising Biomarkers for the Early Detection of Colorectal Neoplasia.

Circulating microRNAs (miRNA) are emerging as promising diagnostic biomarkers for colorectal cancer, but their usefulness for detecting early colorectal neoplasms remains unclear. This study aimed to identify serum miRNA biomarkers for the identification of patients with early colorectal neoplasms. A cohort of 237 serum samples from 160 patients with early colorectal neoplasms (148 precancerous lesions and 12 cancers) and 77 healthy subjects was analyzed in a three-step approach that included a comprehensive literature review for published biomarkers, a screening phase, and a validation phase. RNA was extracted from sera, and levels of miRNAs were examined by real-time RT-PCR. Nine miRNAs (miR-18a, miR-19a, miR-19b, miR-20a, miR-21, miR-24, miR-29a, miR-92, and miR-125b) were selected as candidate biomarkers for initial analysis. In the screening phase, serum levels of miR-21, miR-29a, and miR-125b were significantly higher in patients with early colorectal neoplasm than in healthy controls. Elevated levels of miR-21, miR-29a, and miR-125b were confirmed in the validation phase using an independent set of subjects. Area under the curve (AUC) values for serum miR-21, miR-29a, miR-125b, and their combined score in discriminating patients with early colorectal neoplasm from healthy controls were 0.706, 0.741, 0.806, and 0.827, respectively. Serum levels of miR-29a and miR-125b were significantly higher in patients who had only small colorectal neoplasms (≤5 mm) than in healthy subjects. Because serum levels of miR-21, miR-29a, and miR-125b discriminated patients with early colorectal neoplasm from healthy controls, our data highlight the potential clinical use of these molecular signatures for noninvasive screening of patients with colorectal neoplasia.

Post-operative infection of endoscopic submucosal dissection of early colorectal neoplasms: a case-controlled study using a Japanese database.

Endoscopic submucosal dissection of early colorectal neoplasms (ESD-ECN) is known to be an operation with risk of contamination, possibly requiring pre-operative antimicrobial prophylaxis for the prevention of post-operative infection. However, an evaluation of the need for pre-operative antimicrobial prophylaxis for ESD-ECN has yet to be reported. The objective of this study was to determine whether pre-operative antimicrobial prophylaxis is associated with a reduced incidence of post-operative infection following ESD-ECN. The present retrospective case-controlled study utilized a database built from the medical records of 14 university hospitals throughout Japan. Patients who were admitted and discharged from the hospital from April 2012 to October 2013 and who had undergone ESD-ECN were included in the study. Patients who had been undergone any other operation during their course of hospitalization, and patients who were prescribed antimicrobial agents for reasons other than post-operative infection or for prophylaxis were excluded. Characteristics of the study population, pre-operative antimicrobial prophylaxis and antimicrobial therapy for post-operative infection were investigated. In addition, we compared the characteristics of patients with post-operative infection (PI) and those with no post-operative infection (NPI). Univariate analyses were used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI). We obtained the records of 522 patients who had undergone ESD-ECN from the database. After application of exclusion criteria, 421 patients were enrolled. The post-operative infection rate was 1·2%. Peritonitis was found most to be the most common post-operative infection (44%). Pre-operative antimicrobial prophylaxis was used for 314 patients (75%), with a median duration of 3·0 (range 1-11) days. Cefotiam was most frequently prescribed for pre-operative antimicrobial prophylaxis (56%). Antimicrobial therapies were started 1-10days after ESD-ECN for a duration of 1-14days. Pre-operative antimicrobial prophylaxis was not associated withpost-operative infection rate, with an OR (95% CI) of 0·73 (0·08-6·61). However, digestive tract perforation was shown to be associated with post-operative infection and had an OR (95% CI) of 17·1 (1·66-176·45). Post-operative infection is an exceedingly rare event following ESD-ECN. Pre-operative antimicrobial prophylaxis had no significant effect on post-operative infection following ESD-ECN and thus may be unnecessary. Instead, prevention of digestive tract perforation may be more critical for the decrease in post-operative infections.

Factors for Endoscopic Submucosal Dissection in Early Colorectal Neoplasms: A Single Center Clinical Experience in China.

Background/AimsEarly colorectal (CR) neoplasm can be cured by endoscopic submucosal dissection (ESD), but clinical experience and factors associated with complications from ESD for CR neoplasms in China have not been reported.MethodsSeventy-eight cases of early CR neoplasm treated with endoscopic resection performed between December 2012 and December 2013 at Beijing Military General Hospital were included. Factors associated with ESD complications and procedure times were evaluated.ResultsThe en bloc resection rate was 88.5% (69/78), tumor size was 32.1±10.7 mm, and procedure time was 71.8±49.5 minutes. The major complication was perforation, which occurred in 8.97% of the ESD procedures. Multivariate logistic regression analysis indicated that only tumor size (p=0.022) was associated with ESD perforation. Tumor size (p<0.001) and the non-lifting sign (p=0.017) were independent factors for procedure time, and procedure time (p=0.016) was a key factor for en bloc resection. After a median 10 months (range, 4 to 16) of follow-up, no patients had local recurrence.ConclusionsThis study indicated that ESD is an applicable method for large early CR neoplasm in the colon and rectum. Tumor size and the non-lifting sign might be considerable factors for increased complication rate and procedural time of ESD.

Endoscopic submucosal dissection vs laparoscopic colorectal resection for early colorectal epithelial neoplasia.

To compare the short term outcome of endoscopic submucosal dissection (ESD) with that of laparoscopic colorectal resection (LC) for the treatment of early colorectal epithelial neoplasms that are not amenable to conventional endoscopic removal. This was a retrospective cohort study. The clinical data of all consecutive patients who underwent ESD for endoscopically assessed benign lesions that were larger than 2 cm in diameter from 2009 to 2013 were collected. These patients were compared with a cohort of controls who underwent LC from 2005 to 2013. Lesions that were proven to be malignant by initial endoscopic biopsies were excluded. Mid and lower rectal lesions were not included because total mesorectal excision, which bears a more complicated postoperative course, is not indicated for lesions without histological proof of malignancy. Both ESD and LC were performed by the same surgical unit with a standardized technique. The patients were managed according to a standard protocol, and they were closely monitored for complications after the procedures. All hospital records were reviewed, and the following data were compared between the ESD and LC groups: patient demographics, size and location of the lesions, procedure time, short-term clinical outcomes and pathology results. From 2005 to 2013, 65 patients who underwent ESD and 55 patients who underwent LC were included in this study. The two groups were similar in terms of sex (P = 0.41) and American Society of Anesthesiologist class (P = 0.58), although patients in the ESD group were slightly older (68.6 ± 9.4 vs 64.6 ± 9.9, P = 0.03). ESD could be accomplished with a shorter procedure time (113 ± 66 min vs 153 ± 43 min, P < 0.01) for lesions of comparable size (3.0 ± 1.2 cm vs 3.4 ± 1.4 cm, P = 0.22) and location (colon/rectum: 59/6 vs colon/rectum: 52/3, P = 0.43). ESD appeared to be associated with a lower short-term complication rate, but the difference did not reach statistical significance (10.8% vs 23.6%, P = 0.06). In the LC arm, a total of 22 complications occurred in 13 patients. A total of 7 complications occurred in the ESD arm, including 5 perforations and 2 episodes of bleeding. All perforations were observed during the procedure and were successfully managed by endoscopic clipping without emergency surgical intervention. Patients in the ESD arm had a faster recovery than patients in the LC arm, which included shorter time to resume normal diet (2 d vs 4 d, P = 0.01) and a shorter hospital stay (3 d vs 6 d, P < 0.01). ESD showed better short-term clinical outcomes in this study. Further prospective randomized studies will be required to evaluate the efficacy and superiority of colorectal ESD over LC.

Observation of microvessels and invasion in early colorectal neoplasms on narrow band imaging: combination with CD34 and matrix metalloproteinase-7 expression.

The study aims to clarify the role of narrow band imaging (NBI) in the prediction of invasion depth and the formation of lesion appearance under NBI with immunohistochemical analysis. As a prospective single-center study, Sano's classification of capillary pattern (CP) was applied to differentiate early colorectal neoplasms under NBI observation. Only lesions with CP type III were analyzed, compared with final histologic findings, and further immunohistochemical analysis with CD34 and matrix metalloproteinase-7 (MMP-7) was performed. As for the 203 cases of CP type III lesions, the sensitivity, specificity, and accuracy for CP type IIIA/IIIB were, respectively, 88.4, 93.6, and 92.5% to differentiate high-grade neoplasia or slight submucosal invasive carcinoma from deep submucosal invasive carcinoma. NBI prediction for invasion depth corresponded to immunohistochemical outcomes of CD34 and MMP-7, which might explain the reason why CP type IIIB displays nearly avascular or loose microvascular areas on the lesion surface. NBI is of excellent use in predicting invasion depth for early colorectal neoplasms, and positive expression of MMP-7 is associated with the appearance of CP type IIIB.

Abstract 867: Serum microRNAs as diagnostic biomarkers for early colorectal neoplasms

Abstract Objectives: Early detection of precancerous lesions and early-stage cancers are essential to reduce mortality from colorectal cancer (CRC). Serum/plasma microRNAs (miRs) have been reported as diagnostic and prognostic biomarkers of CRC, but their utility in detecting patients with early lesions has not been fully explored. The aim of this study is to identify serum miRs which are potentially useful as diagnostic biomarkers for early colorectal neoplasms, and potential confounders in a blood test. Methods: Candidate biomarker miRs were selected from previously published studies. Serum samples were collected from patients with low-grade intraepithelial neoplasias (LGINs) including tubular adenomas and tubulovillous adenomas, high-grade intraepithelial neoplasias (HGINs), early cancers, and healthy volunteers, and divided into discovery and validation sets. Total RNA was extracted from serum samples and levels of candidate miRs were measured by real-time RT-PCR. To evaluate the impact of hemolysis on serum miR levels, serially diluted hemolysed controls were prepared from stock solution made by hemolysing the red blood cells in distilled water. Levels of candidate miRs in hemolysed controls were also examined by real-time RT-PCR. Absorbance of serum samples at 560 nm, 576 nm, and 592 nm was measured by spectrophotometry and hemoglobin levels were estimated from a standard curve. Results: Fourteen miRs were selected as candidate diagnostic biomarkers of early colorectal neoplasms from a review of the literature. Serum levels of five miRs were too low to be accurately quantified by real-time RT-PCR, and excluded from further evaluation. Sera from 12 patients with LGINs, 8 patients with HGINs, 4 patients with cancers, and 25 healthy volunteers were included in the discovery phase. Of 9 miRs examined, miR21 (p = 0.0007), miR29a (p &amp;lt; 0.0001) and miR125b (p = 0.0198) showed significantly higher levels in sera from early colorectal neoplasms compared to those from healthy volunteers. Higher levels of miR29a and miR125b in sera from early colorectal neoplasms were confirmed in the validation phase using independent set of samples. Levels of miR21, 29a, and miR125b in sera significantly correlated with the degree of hemolysis. Conclusions: Serum miRs may be useful biomarkers to detect patients with early colorectal neoplasia, including adenomas. Hemolysis affects serum miR levels, and will confound measurement. Since hemolysis occurs frequently during blood collection, its impact on serum miRs should be further investigated. Citation Format: Atsushi Yamada, Takahiro Horimatsu, Yoshinaga Okugawa, Naoshi Nishida, Tadayuki Kou, Toshihiro Kusaka, Hajime Honjo, Yusuke Amanuma, Osamu Kikuchi, Manabu Muto, Ajay Goel, C. Richard Boland. Serum microRNAs as diagnostic biomarkers for early colorectal neoplasms. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 867. doi:10.1158/1538-7445.AM2014-867

Towards improved awareness and earlier diagnosis of early onset colorectal neoplasms.

Towards improved awareness and earlier diagnosis of early onset colorectal neoplasms.

Tu1539 Evaluation of a Novel Approach to Early Stage Colorectal Neoplasms: Endoscopic Submucosal Dissection. a Japanese National Registry Study

Tu1539 Evaluation of a Novel Approach to Early Stage Colorectal Neoplasms: Endoscopic Submucosal Dissection. a Japanese National Registry Study

Incidence, clinical features and possible etiology of early onset (≤40 years) colorectal neoplasms

The aim of the study was to investigate the clinical features, including survival, of patients with colorectal malignancies developed at a very early age (≤40 years), together with possible factors involved in the pathogenesis of these rare neoplasms. The study took advantage of the existence of a specialized colorectal cancer Registry active from 1984. 57 patients met the criteria of early onset cancer; main epidemiological data, morphology, stage, familial aggregation, possible role of inheritance and survival were analyzed. Despite the relevant increase over time of all registered patients, joiningpoint analysis of crude incidence rate of early onset colorectal neoplasms revealed a certain stability of these tumors (EAPC: 2.4, CI 14-22) with a constant prevalence of the male sex. Stage at diagnosis did not show significant variations between early onset and maturity onset colorectal neoplasms. Hereditary as well as familial cases were significantly (P < 0.005 and 0.03) more frequent among patients with early onset tumors, although in the majority of them no specific etiological factor could be identified. Survival was more favorable in patients with early onset tumors, though this had to be attributed to the higher presence of some histological types in early onset cases. Survival was significantly more favorable for patients of all ages registered in the last decade. Incidence of early onset colorectal cancer was relatively stable between 1984 and 2008. A male preponderance was evident through the registration period. Hereditary and familial cases were significantly more frequent among early onset case. A well defined etiology could be observed in 16% of the cases (versus 2-3% in older individuals). Five-year survival showed a significant improvement over time.

Tu1453 The Effect of Preoperative Biopsy on Colorectal Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is increasingly used to resect early colorectal neoplasms despite the technical difficulties associated with this procedure. Colonoscopic biopsies performed for diagnostic purposes may lead to scar and ulcer formation. Since the effects of the diagnostic biopsy prior to colorectal ESD have not been reported, the aim of this study was to investigate the relationship between post-biopsy scarring and the difficulty level of colorectal ESD.

Endoscopic Submucosal Dissection for Early Colorectal Neoplasms: Clinical Experience in a Tertiary Medical Center in Taiwan

Objectives. Endoscopic submucosal dissection (ESD) is a promising technique to treat early colorectal neoplasms by facilitating en bloc resection without size limitations. Although ESD for early gastrointestinal epithelial neoplasms has been popular in Japan, clinical experience with colorectal ESD has been rarely reported in Taiwan. Methods. From March 2006 to December 2011, 92 consecutive patients with early colorectal neoplasms resected by ESD at Tri-Service General Hospital were included. ESD was performed for colorectal epithelial neoplasms with a noninvasive pit pattern which had the following criteria: (1) lesions difficult to remove en bloc with a snare, such as laterally spreading tumors-nongranular type (LST-NG) ≧20 mm and laterally spreading tumors-granular type (LST-G) ≧30 mm; (2) lesions with fibrosis or which had recurred after endoscopic mucosal resection with a nonlifting sign. Results. The mean age of the patients was 66.3 ± 12.9 years, and the male-female ratio was 1.8 : 1. The mean tumor size was 37.2 ± 17.9 mm. The en bloc resection rate was 90.2% and the R0 resection rate was 89.1%. Perforations during ESD occurred in 11 patients (12.0%) and all of them were effectively treated by endoscopic closure with hemoclips. No delayed perforation or postoperative bleeding was recorded. There were no procedure-related morbidities or mortalities. Conclusion. ESD is an effective method for en bloc resection of large early colorectal neoplasms and those with a nonlifting sign. An endoscopic technique to close perforations is essential for colorectal ESD.

Early colorectal epithelial neoplasm in Korea: a multicenter survey of pathologic diagnosis.

BackgroundThe incidence of early colorectal epithelial neoplasm (ECEN) is increasing, and its pathologic diagnosis is important for patient care. We investigated the incidence of ECEN and the current status of its pathologic diagnosis.MethodsWe collected datasheets from 25 institutes in Korea for the incidence of colorectal adenoma with high grade dysplasia (HGD) and low grade dysplasia in years 2005, 2007, and 2009; and early colorectal carcinoma in the year 2009. We also surveyed the diagnostic terminology of ECEN currently used by the participating pathologists.ResultsThe average percentage of diagnoses of adenoma HGD was 7.0%, 5.0%, and 3.4% in years 2005, 2007, and 2009, respectively. The range of incidence rates of adenoma HGD across the participating institutes has gradually narrowed over the years 2005 to 2009. The incidence rate of early colorectal carcinoma in the year 2009 was 21.2%. The participants did not share a single criterion or terminology for the diagnosis of adenoma HGD. The majority accepted the diagnostic terms that distinguished noninvasive, mucosal confined, and submucosal invasive carcinoma.ConclusionsFurther research requirements suggested are a diagnostic consensus for the histopathologic diagnosis of ECEN; and standardization of diagnostic terminology critical for determining the disease code.

Implementation of Endoscopic Submucosal Dissection for Early Colorectal Neoplasms in Sweden

Objectives. Endoscopic submucosal dissection (ESD) is an effective method for en bloc removal of large colorectal tumors in Japan, but this technique is not yet widely established in western countries. The purpose here was to report the experience of implementing colorectal ESD in Sweden. Methods. Twenty-nine patients with primarily nonmalignant and early colorectal neoplasms considered to be too difficult to remove en bloc with EMR underwent ESD. Five cases of invasive cancer underwent ESD due to high comorbidity excluding surgical intervention or as an unexpected finding. Results. The median age of the patients was 74 years. The median tumor size was 26 mm (range 11–89 mm). The median procedure time was 142 min (range 57–291 min). En bloc resection rate was 72% and the R0 resection rate was 69%. Two perforations occurred amounting to a perforation rate of 6.9%. Both patients with perforation could be managed conservatively. One bleeding occurred during ESD but no postoperative bleeding was observed. Conclusion. Our data confirms that ESD is an effective method for en bloc resection of large colorectal adenomas and early cancers. This study demonstrates that implementation of colorectal ESD is feasible in Sweden after proper training, careful patient selection, and standardization of the ESD procedure.

Clinical Practice of Endoscopic Submucosal Dissection for Early Colorectal Neoplasms by a Colonoscopist with Limited Gastric Experience

Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.

Adenoma-linked barrier defects and microbial products drive IL-23/IL-17-mediated tumour growth

Approximately 2% of colorectal cancer is linked to pre-existing inflammation known as colitis-associated cancer, but most develops in patients without underlying inflammatory bowel disease. Colorectal cancer often follows a genetic pathway whereby loss of the adenomatous polyposis coli (APC) tumour suppressor and activation of β-catenin are followed by mutations in K-Ras, PIK3CA and TP53, as the tumour emerges and progresses. Curiously, however, 'inflammatory signature' genes characteristic of colitis-associated cancer are also upregulated in colorectal cancer. Further, like most solid tumours, colorectal cancer exhibits immune/inflammatory infiltrates, referred to as 'tumour-elicited inflammation'. Although infiltrating CD4(+) T(H)1 cells and CD8(+) cytotoxic T cells constitute a positive prognostic sign in colorectal cancer, myeloid cells and T-helper interleukin (IL)-17-producing (T(H)17) cells promote tumorigenesis, and a 'T(H)17 expression signature' in stage I/II colorectal cancer is associated with a drastic decrease in disease-free survival. Despite its pathogenic importance, the mechanisms responsible for the appearance of tumour-elicited inflammation are poorly understood. Many epithelial cancers develop proximally to microbial communities, which are physically separated from immune cells by an epithelial barrier. We investigated mechanisms responsible for tumour-elicited inflammation in a mouse model of colorectal tumorigenesis, which, like human colorectal cancer, exhibits upregulation of IL-23 and IL-17. Here we show that IL-23 signalling promotes tumour growth and progression, and development of a tumoural IL-17 response. IL-23 is mainly produced by tumour-associated myeloid cells that are likely to be activated by microbial products, which penetrate the tumours but not adjacent tissue. Both early and late colorectal neoplasms exhibit defective expression of several barrier proteins. We propose that barrier deterioration induced by colorectal-cancer-initiating genetic lesions results in adenoma invasion by microbial products that trigger tumour-elicited inflammation, which in turn drives tumour growth.

Current research status of endoscopic submucosal dissection for colorectal neoplasms

Endoscopic submucosal dissection (ESD) has been applied to, and gradually standardized for, early gastric cancers; however, it has not yet been widely used for treatment of colorectal neoplasms. Compared with gastric ESD, the thinner colorectal wall and winding nature of the colon make colorectal ESD a much more difficult operative technique. Despite greater risks of postoperative complications, particularly perforation of the colon, more and more endoscopists are making an effort to study this new technique in terms of its capability of larger neoplastic resection, higher en bloc resection rate and lower local recurrence rate of neoplasms in comparison with other endoscopic treatments. Thus, colorectal ESD may become the standard treatment for early colorectal neoplasms in the future. This review article discusses the current research on endoscopic submucosal dissection for colorectal neoplasms. Please see supplementary files for the accompanying video ESD with snare.

849 Fecal Immunochemical Test Has Lower Performance in Detecting Early and Proximal Advanced Colorectal Neoplasm

responders. Secondary endpoints included changes from baseline in weekly, monthly, and overall SBM frequency; time-to-first SBM; and overall mean changes from baseline in OBDrelated symptoms. Results: Significantly more patients in the lubiprostone group than in the placebo group were overall SBM responders during the 12-week treatment (26.9% vs. 18.6%, p=0.035). Overall, weekly and monthly changes from baseline in SBM frequencies demonstrated lubiprostone superiority over placebo overall, and at every treatment week and month, with statistical significance achieved overall (p=0.005), at 8 of the 12 treatment weeks (p≤0.039), as well as at each treatment month (p≤0.041). In addition, median time to first SBM was significantly shorter for lubiprostone-treated patients vs placebo (24.3 vs 38.5 hours, p=0.019), with a significantly higher proportion of lubiprostone patients reporting their first SBM within 4, 8, 12, 24, and 48 hours of first dose (p≤0.022). Straining, stool consistency, and constipation severity were also statistically significantly improved for lubiprostone vs placebo (p=0.002, p<0.001, and p=0.007, respectively). The most common treatment-related adverse events (AEs) reported by lubiprostone-treated patients were diarrhea (9.6%), nausea (8.2%), and abdominal pain (5.5%). There were no drug-related serious AEs reported for patients taking lubiprostone. Conclusion: Lubiprostone significantly improved SBM response and OBD symptoms in this 12-week, placebo-controlled study. Furthermore, lubiprostone was well tolerated in this patient population.

Su1417 Outcomes of Colorectal Endoscopic Submucosal Dissection and Risk Factors for Technical Difficulty: A Prospective Multi-Center Study on Endoscopic Treatment of Large Early Colorectal Neoplasms

Su1417 Outcomes of Colorectal Endoscopic Submucosal Dissection and Risk Factors for Technical Difficulty: A Prospective Multi-Center Study on Endoscopic Treatment of Large Early Colorectal Neoplasms

Su1549 Endoscopic Resection for Sessile and Flat Colorectal Lesions Between High-Volume and Low Volumes Centers in the North of Italy. A Prospective Multicenter Study

endoscopic resection (ER), including endoscopic submucosal resection (ESD), is a therapeutic procedure developed to remove early colorectal neoplasm and it is accepted and widespread in Europe. Outcomes of ER at low-volume centers have been unknown, because previous reports have studied in tertiary single centers.