Resection Of Rectal Carcinoid Tumors Research Articles

The clinical outcomes and risk factors associated with incomplete endoscopic resection of rectal carcinoid tumor.

The risk of lymph node metastasis of a small rectal carcinoid tumor (<10mm) is known to be lower than that of tumors at other gastrointestinal sites. Although rectal carcinoid tumors can be treated by endoscopic resection, the resected specimen may be incomplete. The consequences of an incomplete resection are not well known. From December 2008 to November 2015, cases of rectal carcinoid tumors resected by endoscopic resection techniques such as endoscopic submucosal dissection (ESD), or endoscopic mucosal resection using band ligation device (EMR-L), or cap aspiration (EMR-C) were enrolled. The factors associated with incomplete endoscopic resection and clinical outcomes were retrospectively analyzed. During the study period, a total of 134 rectal carcinoid tumors were resected by endoscopic techniques; ESD (n = 53), EMR-C (n = 65), and EMR-L (n = 16). The mean tumor size was 5.5 ± 2.4mm. The mean follow-up period was 835 ± 501 days. The en bloc resection and complete resection rates were 100 and 85.8%, respectively. Procedure time was longer and the size of the resected tumor was larger in the ESD group than in the EMR-C or EMR-L (p < 0.001) group by the univariate analysis. A factor related to incomplete resection was central depression on the surface (OR 11.529, 95% CI 2.377-55.922, p = 0.002), as revealed by the multivariate analysis. Nineteen patients had an incomplete resection status and did not undergo additional resection treatment; none of these patients had recurrence during the study period. A rectal carcinoid tumor with a central depression on the surface was associated with a higher incomplete resection rate. After an incomplete resection of small rectal carcinoid tumors, without evidence of lymphovascular invasion, a periodic follow-up examination without additional resection may be recommended.

Comparison of endoscopic therapies for rectal carcinoid tumors: Endoscopic mucosal resection with circumferential incision versus endoscopic submucosal dissection

Although various endoscopic resection techniques have been established for rectal carcinoid tumors, there remains controversy regarding the best endoscopic treatment modality for these tumors. This study aimed to evaluate and compare the therapeutic efficacy and safety of EMR with circumferential incision (EMR-CI) and endoscopic submucosal dissection (ESD) for endoscopic resection of rectal carcinoid tumors. From March 2012 to June 2016, 66 rectal carcinoid tumors in 66 patients were resected by using EMR-CI (n=30) or ESD (n=36). The rates of both en bloc resection and complete resection, procedure time, procedure-related complications, and local or metastatic recurrence were analyzed retrospectively. The en bloc resection rate was 96.7% (29/30) and 100% (36/36) for EMR-CI and ESD groups, respectively, and the difference was not statistically significant (P=0.455). The complete resection rate of the ESD group was 97.2% (35/36) and significantly higher than 76.7% (23/30) of the EMR-CI group (P=0.030). The mean procedure time of the ESD group was 20.44±6.64minutes, which was significantly longer than that of the EMR-CI group at 8.47±3.40minutes (P<0.001). The complication rates for ESD and EMR-CI did not differ significantly (0% for EMR-CI vs. 2.8% for ESD, P=1.000). No local or metastatic recurrence was found in either group during the follow-up period. This study suggested that ESD may be a safe, effective, and feasible endoscopic technique for removing rectal carcinoid tumors. ESD showed a similar safety profile and superior efficacy to EMR-CI.

Treatment outcomes of endoscopic resection for rectal carcinoid tumors: an analysis of the resectability and long-term results from 46 consecutive cases

Aim: In Japan, most of colorectal carcinoid tumors developed in rectum. The choice of treatment is important because surgical treatment may need to construct artificial anus. Although curative endoscopic resection (ER) is desirable from the point of quality of life, sufficient evidence of endoscopic treatment for rectal carcinoid tumors is not fully obtained.Methods: Between April 2001 and August 2013, 46 rectal carcinoid tumors in 46 patients who underwent either with endoscopic mucosal resection with a ligation device (EMR-L) or endoscopic submucosal dissection (ESD) were analyzed retrospectively. The rates of en bloc resection, positive for lateral and/or vertical margin, curative resection, local recurrence, additional treatments, overall and disease-specific survival rate after ER were evaluated during follow-up (median observation period 61.6 months).Results: Twenty-two lesions were treated by EMR-L and 24 lesions were treated by ESD. Both groups had similar mean tumor size (EMR-L: 6.2 mm, ESD: 6.0 mm). The rate of en bloc resection, negative for both lateral and vertical margins, and curative resection were, respectively, 73%, 63%, and 50% for EMR-L, 100%, 100%, and 83% for ESD. These results suggested that the rate of resectability and curability for ESD was significantly higher than EMR-L (p < 0.05). Complications such as perforation and bleeding did not occur in both groups. Fifteen patients were judged as non-curative and 3 patients underwent additional surgery and lymph node metastasis was evident in 1 patient. Remained 11 patients were carefully followed-up, and so far no obvious recurrence was found. Thirty-two patients (84%) were eligible for long-term follow-up and 5-year overall and disease-specific survival rates were 100% and 100%, respectively.Conclusion: The long-term outcomes of ER for rectal carcinoid tumors were excellent. ESD has advantage for resectability and curability compared with EMR-L; therefore, ESD is more favorable procedure as treatment for rectal carcinoid tumors.

The effect of preceding biopsy on complete endoscopic resection in rectal carcinoid tumor.

Biopsy of rectal carcinoid tumor is commonly taken before endoscopic resection. However the preceding biopsy can inhibit complete resection by causing blurred tumor border and fibrosis of the tissue. The objective of the study was to investigate the effect of preceding biopsy on complete endoscopic resection in rectal carcinoid tumor. It was also determined if rectal carcinoid tumors can be macroscopically distinguished by endoscopy. We reviewed retrospectively the records of patients with rectal carcinoid tumor who had undergone an endoscopic treatment at our hospital, during a 7-yr period. The resection margin was clear in 57 of 98 cases. The preceding biopsy was taken in 57 cases and the biopsy was significantly associated with the risk of incomplete tumor resection (OR, 3.696; 95% CI, 1.528-8.938, P = 0.004). In 95.9% of the cases, it was possible to suspect a carcinoid tumor by macroscopic appearance during initial endoscopy. The preceding biopsy may disturb complete resection of rectal carcinoid tumor. In most cases, the carcinoid tumor could be suspected by macroscopic appearance. Therefore the preceding biopsy is not essential, and it may be avoided for the complete resection.

Tu1431 Treatment Outcomes of Endoscopic Resection for Rectal Carcinoid Tumors: an Analysis of Resectability and Long-Term Result of 37 Consecutive Cases

Most of colorectal carcinoid tumors developed in rectum in Japan, and 80% of those were especially located less than 10 cm from dentate line. The choice of treatment either endoscopic or surgical resection is very important because surgical treatment for those tumors may need to construct artificial anus. Although curative endoscopic resection (ER) is desirable from the point of maintaining of QOL, sufficient evidence of endoscopic treatment for rectal carcinoid tumors is not fully obtained. The aim of this study is to clarify the efficacy of ER for rectal carcinoid tumors and long-term consequences.

Tips and Tricks for Better Endoscopic Treatment of Colorectal Tumors: Usefulness of Cap and Band in Colorectal Endoscopic Mucosal Resection

Endoscopic mucosal resection (EMR) is an endoscopic alternative to surgical resection of mucosal and submucosal neoplastic lesions. Prior to the development of knives, EMR could be performed with accessories to elevate the lesion. After the development of various knives, en bloc resection was possible without other accessories. So, recently, simple snaring without suction or endoscopic submucosal dissection using knife in the epithelial lesions such as adenoma or early mucosal cancer has been performed. However, for easy and complete resection of subepithelial lesions such as carcinoid tumor, a few accessories are needed. Complete resection of rectal carcinoid tumors is difficult to achieve with conventional endoscopic resection techniques because these tumors often extend into the submucosa. The rate of positive resection margin for tumor is lower in the group of EMR using a cap (EMR-C) or EMR with a ligation device (EMR-L) than conventional EMR group. EMR-C and EMR-L (or endoscopic submucosal resection with a ligation device) may be a superior method to conventional EMR for removing small rectal carcinoid tumors.

Factors associated with complete local excision of small rectal carcinoid tumor

Although small rectal carcinoid tumors can be treated using local excision, complete resection can be difficult because tumors are located in the submucosal layer. We evaluate the factors associated with pathologically complete local resection of rectal carcinoid tumors. Data were analyzed of 161 patients with 166 rectal carcinoid tumors who underwent local excision with curative intent from January 2001 to December 2010. A pathologically complete resection (P-CR) was defined as an en bloc resection with tumor-free lateral and deep margins. The study classified treatments into three categories for analysis: conventional polypectomy (including strip biopsy, snare polypectomy, and hot biopsy), advanced endoscopic techniques (including endoscopic mucosal resection with cap and endoscopic submucosal dissection), and surgical local excision (including transanal excision and transanal endoscopic microsurgery). We evaluated the P-CR rate according to treatment method, tumor size, initial endoscopic impression and the use of endoscopic ultrasound (EUS) or transrectal ultrasound (TRUS). The mean tumor size was 5.51 ± 2.43mm (range 2-18mm) and all lesions were confined to the submucosal layer. The P-CR rates were 30.9, 72.0, and 81.8% for conventional polypectomy, advanced endoscopic techniques, and surgical local excision, respectively. Univariate analysis showed that P-CR was associated with treatment method, use of EUS or TRUS, and initial endoscopic impression. Multivariate analysis showed that only treatment method was associated with P-CR. Pathologically complete resection of small rectal carcinoid tumors was more likely to be achieved when using advanced endoscopic techniques or surgical local excision rather than conventional polypectomy.

A Comparative Study on Endoscopy Treatment in Rectal Carcinoid Tumors

To investigate the advantages and disadvantages of various endoscopic resection methods for rectal carcinoid tumors. A retrospective analysis of 3 types of endoscopic resection techniques for rectal carcinoid tumors was performed. The surgical time and the complication rate were compared between 30 patients who underwent conventional endoscopic mucosal resection (EMR), cap-assisted endoscopic mucosal resection (EMR-C), or endoscopic submucosal dissection (ESD). All rectal carcinoid tumors were under 1 cm and were treated in our center between January 2002 and January 2008. Ten patients underwent each surgical approach. All cases were pathologically diagnosed as rectal carcinoid tumors. One-time complete resection rates using the conventional EMR, EMR-C, and ESD were 80%, 100%, and 100%, respectively. The operation time ranged from 5 to 53 minutes for the conventional EMR group, from 4 to 7 minutes for the EMR-C group, and from 16 to 35 minutes for the ESD group. The average follow-up time for the 30 patients was 18.43 ± 9.76 months. There were no recurrent or metastatic cases. Endoscopic resection for rectal carcinoid tumors below 1 cm was safe. Considering the clinical efficacy, surgical time, and intraoperative complication rate, EMR-C may be the best endoscopic excision method.

Endoscopic Resection for Rectal Carcinoid Tumors: Comparision of Polypectomy and Endoscopic Submucosal Resection with Band Ligation

Background/AimsRectal carcinoid tumors, at diagnosis, are as small as 10 mm or less in about 80% of patients. These tumors are generally removed by endoscopic resection. The aim of this study was to compare treatment efficacy and safety between endoscopic submucosal resection with band ligation (ESMR-L) and conventional polypectomy.MethodsBetween January 2005 and September 2010, a total of 88 patients, who visited at Busan Paik Hospital and Kosin University Gospel Hospital for endoscopic resection of rectal carcinoid, were reviewed, retrospectively.ResultsThirty-three cases were treated by ESMR-L, and 55 cases by conventional polypectomy. There were no significant difference in the size of tumor between ESMR-L group and polypectomy group (6.02±2.36 vs. 6.49±3.24 mm, p=0.474). The rate of positive resection margin was significantly lower in ESMR-L group (2/33, 6.1%) than in polypectomy group (19/55, 34.5%; p=0.002). The rate of positive vertical resection margin, among others, was markedly lower in ESMR-L group (1/33, 3.0%) compared to polypectomy group (19/55, 34.5%; p<0.001).ConclusionsESMR-L, rather than conventional polypectomy, is a useful treatment option for removal of rectal carcinoid tumors less than 10 mm in diameter.

Rectal Carcinoid Tumors: Pitfalls of Conventional Polypectomy

See Resection for Rectal Carcinoid Tumors: Comparision of Polypectomy and Endoscopic Submucosal Resection with Band Ligation by Sang Heon Lee, Seun Ja Park, Hyung Hun Kim, et al., on page 89-94 Endoscopic therapy has been accepted as an appropriate and safe therapeutic option for small (≤10 mm), well-differentiated rectal carcinoid tumors without any signs of infiltration to the muscularis propria, lymphovascular invasion, or lymph node metastases. However, in terms of both complete resection and complications, the best modality of endoscopic therapy is a matter of debate. The article by Lee et al.1 suggests endoscopic submucosal resection with band ligation (ESMR-L) as a feasible method with a lower rate of complication and a higher rate of the complete resection in comparison to conventional polypectomy. Since the incidence of rectal carcinoid tumors is recently on the rise by the widespread performance of screening colonoscopy and the size of the tumors is also becoming smaller when they are incidentally identified, endoscopic therapy such as snare polypectomy is frequently performed in various medical facilities including private clinics.2 However, rectal carcinoid tumors demonstrate various clinical behaviors, from benign to metastatic tumors, although they are relatively slow-growing.3 Therefore, complete resection is important; however, conventional polypectomy has a high possibility of incomplete resection due to slipping during snaring. Furthermore, rectal carcinoid tumors originate from deep mucosal layer and invades submucosal layer; conventional polypectomy is more appropriate for the management of tumors originating from the mucosal layer.4 This article highlights the potential risk of remnant tumors using conventional polypectomy by showing a high rate of incomplete resection (19/55, 34.5%) compared to ESMR-L (2/33, 6.1%). However, this study is limited by its retrospective design, the small number of patients enrolled in the study (33 cases in ESMR-L vs. 55 cases in conventional polypectomy), and participation of only two institutions which differed in their preferred endoscopic resection methods, as mentioned in the article. Accordingly, further multi-center, large-scaled studies for comparing the rate of complete resection and complications among various modalities of endoscopic therapies are warranted. In addition, how to treat remnant tumors left by incomplete resection after primary resection by either conventional polypectomy or ESMR-L deserves consideration. Particularly, because the rate of incomplete resection in even ESMR-L (2/33, 6.1%) is not low enough to be considered safe, residual scars by ESMR-L are wider and deeper than those by conventional polypectomy, and resection of the remnant tumors is not as simple as primary resection because of the submucosal fibrosis of residual tissue, it is questionable how 21 patients with remnant tumors by incomplete resection (two patients in ESMR-L and 19 patients in conventional polypectomy) were treated after confirmation of the positive resection margin. In a recently published article concerning the salvage therapy for remnant rectal carcinoid tumors,5 although all patients with a positive resection margin showed negative endoscopic and histological findings on a biopsy of the scarred tissue during the surveillance by endoscopic follow-up, the pathologic results from all tissues obtained by salvage resection proved to be microscopic margin positive. This implies that a biopsy alone should not be used to confirm the absence of remnant tumors because of false negative results due to embedding of the residual remnant tumor during tissue healing after the primary resection. Thus, cases with a positive resection margin require salvage resection. Thereby, careful selection of an appropriate primary resection method for complete resection is important to avoid salvage therapy of remnant carcinoid tumors. Nevertheless, this article is significant to reaffirming the risk of conventional polypectomy as a modality of endoscopic therapy for rectal carcinoid tumors in terms of incomplete resection and to corroborate the feasibility of ESMR-L as a therapeutic option with a relatively high rate of complete resection and a low rate of complications.

EFFICACY OF ENDOSCOPIC SUBMUCOSAL RESECTION WITH A LIGATION DEVICE FOR REMOVING SMALL RECTAL CARCINOID TUMOR COMPARED WITH ENDOSCOPIC MUCOSAL RESECTION: ANALYSIS OF 100 CASES

Conventional endoscopic mucosal resection (EMR) of carcinoid tumors is often associated with involvement of the resection margin, which necessitates further intervention. Endoscopic submucosal resection with a ligation device (ESMR-L) is a novel technique for the removal of carcinoid tumors. The aim of the present study was to compare the clinical usefulness of endoscopic submucosal resection with a ligation device with that of EMR for the complete resection of rectal carcinoid tumors. Between January 2001 and October 2010, a total of 100 patients with 100 rectal carcinoid tumors that were estimated to be 10 mm or less in diameter and that were resected either using ESMR-L or EMR were recruited for this study. The complete resection rate and complications associated with these two procedures were analyzed. Forty-five out of 100 lesions were resected using ESMR-L, and 55 lesions were resected using EMR. Histopathologically, all tumors were free from lymphovascular and perineural invasion. The overall ESMR-L complete resection rate was higher than that of EMR (93.3% vs 65.5%, respectively, P = 0.001). Furthermore, the location of the tumors had no influence on the complete resection rate when ESMR-L was carried out, in contrast to the results of EMR. The procedure-related variables of procedure time and complication rate were not significantly different between the two groups. ESMR-L is a significantly superior modality to EMR for the complete removal of small rectal carcinoid tumors that are 10 mm or less in diameter.

Endoscopic mucosal resection for rectal carcinoid tumors

Objective To explore the long-term efficacy of endoscopic sphincterotomy （EST） for choledocholithiasis and to evaluate the necessity of cholecystectomy after EST. Methods Two hundred and fifty seven patients who underwent EST for choledocholithiasis in 2006 were followed up for an average period of 34. 8 months （26-48 months）. According to the existence of cholecystolithiasis, the patients were divided into group A （combined with cholecystolithiasis, n = 151） and group B （without cholecystolithiasis, n = 106） , and group A was further divided into group A1 as undergoing cholecystectomy after EST （n =56） and group A2 as not having cholecystectomy after EST （ n = 95）. Results Of the 257 patients, late complications occurred in 31 patients （12. 1% ） , including recurrent choledocholithiasis in 25 （9.7% ）, cholangitis in 27 （10. 1% ） , acute pancreatitis in 2 （0. 8% ） and cholangiocarcinoma in 1 （0.4% ）. The rates of late complications and recurrent choledocholithiasis were significantly higher in group A2 than those in group A1 （P〈0.05）. Conclusion EST is safe and effective for choledocholithiasis. Cholecystectomy after EST is necessary in patients with cholecystolithiasis. Key words: Carcinoid tumor; Rectum; Endoscopic mucosal resection

Endoscopic Submucosal Dissection or Conventional Endoscopic Mucosal Resection Is an Effective and Safe Treatment for Rectal Carcinoid Tumors: A Retrospective Study

Various methods for complete endoscopic resection of rectal carcinoid tumors have been reported. The aim of the present study was to evaluate the clinical usefulness of endoscopic submucosal dissection (ESD) as a new method or conventional endoscopic mucosal resection (EMR) in order to remove rectal carcinoid tumors completely. Between April 2004 and June 2009, 12 patients with rectal carcinoid tumors, estimated at 10 mm, more or less, in diameter, without atypical features and dissected by ESD or resected by EMR, were recruited for this analysis. The complete dissection or resection rate, complications associated with the procedure, local recurrence, and distant metastases were evaluated. Twelve patients were 9 males and 3 females with a mean age of 47.6 years (range, 32-64). The patients had no complaints of carcinoid syndrome symptoms. Tumor size ranged from 5 to 13 mm in diameter, with an average size of 8.8 mm, and 11 of 12 patients (92.7%) had tumors of diameter less than 10 mm. Three of 12 patients (25.0%) were treated by ESD and 9 (75.0%) by conventional EMR. All lesions, including 13-mm-sized carcinoid tumors, were histologically determined to be completely dissected or resected. There were no immediate or late complications (i.e., bleeding or perforation) after ESD or conventional EMR. Histopathologically, there was no tumor invasion beyond the submucosal layer, and all were classified as classical-type carcinoids without lymphovascular invasion. Neither local recurrence nor distant metastasis were detected during a median follow-up period of 28 months. In this study, ESD as a new method or conventional EMR shows promise or potential as a useful, safe procedure to dissect or resect rectal carcinoid tumors of 10 mm, more or less, in diameter. However, long-term outcome remains to be elucidated by a large-scale, prospective study.

Selection of Cap Size in Endoscopic Submucosal Resection with Cap Aspiration for Rectal Carcinoid Tumors

Small rectal carcinoid tumors (<or=1 cm in diameter) can be treated by endoscopic resection, but complete resection may be difficult if tumors are located in the deep submucosal layer. This study was performed to identify the clinicopathologic factors affecting the complete resection of small rectal carcinoid tumors, using the endoscopic submucosal resection with cap aspiration technique (ESMR-C). Forty-one consecutive patients with 42 rectal carcinoid tumors who underwent ESMR-C from October 2003 to November 2006 were assessed. Complete resection was defined as a clean margin that was free of tumor invasion at the lateral and inferior edges. The rate of complete tumor removal by ESMR-C was 85.7% and no complications occurred. The tumor size, location, and method of resection did not significantly affect the completeness of resection. Univariate analysis showed that the rate of complete resection was significantly higher when using 19.2-mm, compared with 13.9-mm, caps (96.0 vs. 70.6%; P = 0.032). Multivariate analysis showed that the cap size was an independent factor predicting the completeness of resection. The use of large-sized caps increases the completeness of the resection of rectal carcinoid tumors when using ESMR-C.

Endoscopic submucosal resection with a ligation device is an effective and safe treatment for carcinoid tumors in the lower rectum

Various methods for complete endoscopic resection of rectal carcinoid tumors have been reported; however, the number of cases investigated in each study has been limited. The aim of the present study was to clarify the clinical usefulness of a novel technique named endoscopic submucosal resection with a ligation device (ESMR-L) in a large number of rectal carcinoid tumors. Between January 1999 and March 2005, a total of 61 patients with 63 rectal carcinoid tumors estimated at 10 mm or less in diameter, without atypical features and resected by ESMR-L were recruited for this analysis. The complete resection rate, complications associated with the procedure, local recurrence, and distant metastases were evaluated. Sixty-one patients were 36 males and 25 females with a mean age of 59 +/- 11 years (24-76 years). Tumor size ranged from 2 to 12 mm in diameter, with an average size of 6.4 +/- 2.4 mm. Fifty-nine lesions (93.6%) were located in the lower rectum (Rb), three in the upper rectum (Ra) and one in the recto-sigmoid colon (Rs). In total, 60 out of 63 lesions (95.2%) were histologically determined to be completely resected. The complete resection rate for lesions located in the Rb was 98.3%, which was significantly higher than that for lesions in Ra and Rs (50%). Minor bleeding associated with the procedure occurred in five lesions (7.9%), but all cases were successfully managed with hemoclips. Histopathologically, all tumors were located in the submucosal layer, and all were classified as classical-type carcinoids without lymphovascular invasion. Neither local recurrence nor distant metastasis was detected during a median follow-up period of 24 months. In a large number of cases, ESMR-L proved to be a useful and safe procedure to resect rectal carcinoid tumors 10 mm or less in diameter, especially for those located in the Rb.

Curative Resection of Rectal Carcinoid Tumors with Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery is a minimally invasive technique for local resection of rectal tumors. Its place needs to be defined for resection of carcinoid tumors of the rectum. From 1998 to 2004, rectal carcinoid tumors were diagnosed in 5 patients. The diagnosis was suggested at biopsy in all patients. All tumors were resected full thickness with transanal endoscopic microsurgery. Data were obtained retrospectively from a review of hospital charts. At the time of operation all tumors were small without clinical or biochemical signs of metastasis. All resected tumors were highly differentiated and had free margins without invasion into the submucosa. Operative times ranged from 15 to 35 minutes. Hospital stays ranged from 2 to 4 days. No morbidity or mortality was observed. Follow-up ranged from 3 to 75 months. No recurrences were observed. Transanal endoscopic microsurgery is an excellent technique for removal of carcinoid tumors of the rectum and even the distal part of the sigmoid, if the diameter is <1 cm without invasion of the rectal wall.

Clinical Usefulness of Endoscopic Submucosal Resection with Double Ligations for Rectal Carcinoid Tumor in Comparison with Strip Biopsy

Purpose: Complete resection of rectal carcinoid tumors is difficult with conventional polypectomy because these tumors extend mainly into submucosal layer. And deeper incision to achieve clean margin can make complications such as bleeding or perforation. In this study, we evaluated the efficacy and safety of endoscopic submucosal resection with double ligations (ESMR-DL) for the treatment of small rectal carcinoid tumors in comparison with strip biopsy. Methods: We performed strip biopsy or ESMR-DL between April 2000 and November 2004. Eleven carcinoid tumors were resected by strip biopsy, and eleven tumors were resected by ESMR-DL. ESMR-DL was carried out with a conventional single channel endoscope with attached band ligator device. The lesion was aspirated into the ligator device, followed by deployment of the elastic band. And then ligation was performed below the elastic band by using a detachable snare. Snare resection was performed above the elastic band. ESMR-DL was compared with strip biopsy regarding complete resection rate, distance of vertical resection margin, and complication rate. Results: Two groups were similar with respect to location, shape, and size of tumors. The rate of complete removal of carcinoid tumors with ESMR-DL (100%) was significantly higher (p= 0.035) than that with strip biopsy (55%). The mean vertical resection margin in ESMR-DL (832.3 ± 589.4 μ) also was significantly deeper (p= 0.001) than that in strip biopsy (158.6 ± 24.7 μ). The rate of complications with ESMR-DL (0%) was significantly lower (p= 0.035) than that of strip biopsy (45%). There was no local recurrence or distant metastases in any patients treated with ESMR-DL during the mean follow-up period of 24 months. Conclusions: Endoscopic submucosal resection with double ligations is a useful and safe method for the treatment of small rectal carcinoid tumors. [figure 1]Figure

Is a second ligation necessary in endoscopic submucosal resection of rectal carcinoid tumors?

With great interest, we have read the article of Moon et al. on endoscopic submucosal resection with a double ligation technique for treatment of rectal carcinoid tumors [1]. They have modified our technique of endoscopic submucosal resection with a ligation device (ESMR-L) [2]; that is, they have applied a second detachable snare to ligate the stalk below the elastic band and performed snare resection above the elastic band. They have employed this modified technique for complete removal of 11 rectal carcinoid tumors, without immediate or late complication such as bleeding or perforation. They concluded that it is a useful and safe method for the treatment of small rectal carcinoid tumors.

Endoscopic Submucosal Resection with Double Ligation Technique for Treatment of Small Rectal Carcinoid Tumors

It is difficult to achieve complete endoscopic resection of rectal carcinoid tumors without any procedure-related complications. In this study, we evaluated the efficacy and safety of endoscopic submucosal resection with double ligation (ESMR-DL) for the treatment of small rectal carcinoid tumors. Eleven rectal carcinoid tumors (in 11 patients) were resected by ESMR-DL between November 2001 and April 2004, using a conventional single-channel endoscope with an attached band-ligator device. The lesion was aspirated into the ligator device and an elastic band was placed around the base; a detachable snare was then used to ligate the stalk below the elastic band; and snare resection was performed above the elastic band. The resected specimens were examined with respect to size, histological atypia, depth of invasion, and the histological appearance of the resection margins. All the lesions were excised completely without any complications. There was no tumor invasion beyond the submucosal layer and there was no evidence of atypia in any of the specimens. Tumor diameter varied from 2.0 mm to 10.0 mm (average 6.2 mm). None of the 11 specimens showed histopathological evidence of tumor involvement at the resection margins. There were no immediate or late complications (bleeding or perforation) after ESMR-DL. There was no local recurrence and there were no distant metastases in any patients during the mean follow-up period of 18 months. Endoscopic submucosal resection with double ligation is a useful and safe method for the treatment of small rectal carcinoid tumors.

The Evaluation of the Endoscopic Submucosal Resection of Rectal Carcinoid Tumors with Ligation Device

Background: Rectal carcinoid tumor is uncommon and grows slowly, however, even minute tumors less than 10 mm in diameter have the risk of liver metastasis. Although complete resection of the tumors infiltrating into submucosal layer is required, simple snare resection is difficult to remove them completely because of the existence of local remnant portions. Recently endoscopic submucosal resection with a ligation device (ESMR-L) has been reported to be able to remove small rectal carcinoid completely and safely.