Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video).

BACKGROUND Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer; however, it is not widely used in the colorectum because of its technical difficulty. OBJECTIVE To determine the feasibility of using ESD for treating large superficial colorectal tumors and to evaluate the clinical outcome. DESIGN AND SETTING Case series conducted at the National Cancer Center Hospital in Tokyo. PATIENTS A total of 198 consecutive patients were treated for 200 lesions. INTERVENTIONS Procedures were performed, before July 2004, by using a monopolar needle knife or an insulation-tipped knife (IT knife). After July 2004, the procedures were performed by using a bipolar needle knife or an IT knife. After injection of glycerol and sodium hyaluronate acid into the submucosal (sm) layer, a circumferential incision was made and sm dissection was performed endoscopically. MAIN OUTCOME MEASUREMENTS The en bloc resection rate was 84% and the curative resection rate was 83%. RESULTS Among the 200 ESDs, 51 involved tubular adenomas, 99 intramucosal cancers, 22 minute sm cancers, and 28 sm deep cancers. The median operation time was 90 minutes, and the mean size of resected specimens was 38 mm (range, 20-150 mm). Perforations occurred in 10 cases (5%) and postoperative bleeding in 4 cases (2%), but only 1 perforation case needed emergency surgery, because endoscopic clipping was ineffective. LIMITATIONS No long-term outcome data yet. CONCLUSIONS ESD is a feasible technique for treating large superficial colorectal tumors, because it provides a higher en bloc resection rate and is less invasive than surgical resection.

[1]  Hiroaki Ikematsu,et al.  A new sinker-assisted endoscopic submucosal dissection for colorectal cancer. , 2005, Gastrointestinal endoscopy.

[2]  H. Tajiri,et al.  Assessment of colorectal lesions using magnifying colonoscopy and mucosal dye spraying: can significant lesions be distinguished? , 2001, Endoscopy.

[3]  K. Okita,et al.  Endoscopic Resection of Early Gastric Cancer , 1993, Endoscopy.

[4]  J. Fleshman,et al.  A comparison of laparoscopically assisted and open colectomy for colon cancer. , 2004, The New England journal of medicine.

[5]  H. Tajiri,et al.  New Endoscopic Treatment for Intramucosal Gastric Tumors Using an Insulated-Tip Diathermic Knife , 2001, Endoscopy.

[6]  P. Deyhle,et al.  A Method for Endoscopic Electroresection of Sessile Colonic Polyps , 1973 .

[7]  T. Matsuda,et al.  Effectiveness of glycerol as a submucosal injection for EMR. , 2005, Gastrointestinal endoscopy.

[8]  S. Cross,et al.  A prospective analysis of extended endoscopic mucosal resection for large rectal villous adenomas: an alternative technique to transanal endoscopic microsurgery , 2005, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[9]  Hirohisa Ueda,et al.  Magnetic anchor for more effective endoscopic mucosal resection. , 2004, Japanese journal of clinical oncology.

[10]  B. Ghadimi,et al.  Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection , 2003, International Journal of Colorectal Disease.

[11]  M F Dixon,et al.  The Vienna classification of gastrointestinal epithelial neoplasia , 2000, Gut.

[12]  A. Repici,et al.  EMR of large sessile colorectal polyps. , 2004, Gastrointestinal endoscopy.

[13]  Y. Sano,et al.  A newly developed bipolar-current needle-knife for endoscopic submucosal dissection of large colorectal tumors. , 2006, Endoscopy.

[14]  R. Walsh,et al.  Endoscopic resection of large sessile colorectal polyps. , 1992, Gastrointestinal endoscopy.

[15]  H. Ono,et al.  A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. , 1999, Gastrointestinal endoscopy.

[16]  K. Sugano,et al.  Successful En-Bloc Resection of Large Superficial Tumors in the Stomach and Colon Using Sodium Hyaluronate and Small-Caliber-Tip Transparent Hood , 2003, Endoscopy.

[17]  K. Sugano,et al.  Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate. , 2002, Gastrointestinal endoscopy.

[18]  M. Omata,et al.  Endoscopic submucosal dissection using flexknife. , 2006, Journal of clinical gastroenterology.

[19]  Jinnai Dennosuke,et al.  General rules for clinical and pathological studies on cancer of the colon, rectum and anus , 1983 .

[20]  Y. Sano,et al.  ENDOSCOPIC MUCOSAL RESECTION AND SUBMUCOSAL DISSECTION METHOD FOR LARGE COLORECTAL TUMORS , 2004 .

[21]  E. Furth,et al.  Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases. , 2002, Gastrointestinal endoscopy.

[22]  K. Hosokawa,et al.  [Recent advances in endoscopic mucosal resection for early gastric cancer]. , 1998, Gan to kagaku ryoho. Cancer & chemotherapy.

[23]  T. Gotoda,et al.  Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum , 2006, Gut.

[24]  T. Fujii,et al.  Endoscopic treatment for laterally spreading tumors in the colon. , 2001, Endoscopy.

[25]  T. Matsuda,et al.  A pilot study to assess the safety and efficacy of carbon dioxide insufflation during colorectal endoscopic submucosal dissection with the patient under conscious sedation. , 2007, Gastrointestinal endoscopy.

[26]  N. Soehendra,et al.  Endoscopic mucosal resection. , 2003, Endoscopy.

[27]  Y. Sano,et al.  Iatrogenic perforation at therapeutic colonoscopy: should the endoscopist attempt closure using endoclips or transfer immediately to surgery? , 2006, Endoscopy.

[28]  S. Kudo,et al.  Endoscopic Mucosal Resection of Flat and Depressed Types of Early Colorectal Cancer , 1993, Endoscopy.

[29]  K. Chayama,et al.  Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. , 2001, Gastrointestinal endoscopy.

[30]  Shin-ei Kudo,et al.  Colonoscopic Diagnosis and Management of Nonpolypoid Early Colorectal Cancer , 2000, World Journal of Surgery.

[31]  S. Yoshida,et al.  Endoscopic mucosal resection for treatment of early gastric cancer , 2001, Gut.

[32]  Y. Sano,et al.  Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study. , 2004, Endoscopy.

[33]  Hironori Yamamoto,et al.  Endoscopic submucosal dissection of early cancers and large flat adenomas. , 2005, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[34]  K. Sugano,et al.  Successful en bloc resection of a large superficial gastric cancer by using sodium hyaluronate and electrocautery incision forceps. , 2001, Gastrointestinal endoscopy.

[35]  S. Cross,et al.  A prospective evaluation of high-magnification chromoscopic colonoscopy in predicting completeness of EMR. , 2004, Gastrointestinal endoscopy.

[36]  Takahiro Kozu,et al.  Percutaneous traction-assisted EMR by using an insulation-tipped electrosurgical knife for early stage gastric cancer. , 2004, Gastrointestinal endoscopy.

[37]  T. Fujii,et al.  Chromoscopy During Colonoscopy , 2001, Endoscopy.

[38]  Ming-Yao Su,et al.  Magnifying colonoscopy in differentiating neoplastic from nonneoplastic colorectal lesions , 2001, American Journal of Gastroenterology.

[39]  S. Yoshida,et al.  Endoscopic mucosal resection for colorectal neoplastic lesions , 1994, Diseases of the colon and rectum.