Introduction
Scarred colo-rectal lesions still represent an endoscopic challenge due to technical feasibility and histologic radicality. The optimal endoscopic technique of choice remains controversial.
Endoscopic submucosal dissection (ESD) has been proposed as an option since it allows “en-bloc” resection and low rates of recurrence [1],[2]. Nevertheless, it represents a time-consuming procedure, burdened by complications in non-experts’ hands. Hybrid ESD (H-ESD), has been suggested as rescue therapy in cases where complete ESD is not feasible [3].
Aims & Methods
We retrospectively analyzed a prospectively collected cohort of 180 patients who underwent ESD for scarred colorectal lesions at San Raffaele Scientific Institute in Milan and Arcispedale Santa Maria Nuova, Reggio Emilia, Italy, between January 2009 and October 2022. Procedures were performed by expert endoscopists, who had completed more than 60 colo-rectal ESD. Primary outcome was to assess technical success, defined as the completion of an “en-bloc” ESD. Technical failure was defined as the need of conversion to H-ESD to complete the procedure. Secondary outcomes included: curative resection (cR), defined as submucosal invasion < 1,000-micron, complete resection (CR), defined as en-bloc resection with free histologic margins and recurrence rate at follow-up. Lesions characteristics, technical data of procedures, adverse events rate were also collected. Predictive factors of technical success were assessed through univariate analysis and multivariate logistic regression.
Results
Mean age was 68.42±11.4 years (range 38-89), with a 56/44 female to male ratio. Most of the lesions were in the rectum (50.6%), followed by left colon (13.9%), transversum (9.4%) and right colon (26.1%). Grade of fibrosis was mostly severe (F3 56.7%; F2 24.4%; F1 18.9%), due to previous treatment attempts (70.6%) or biopsy sampling (29.4%). Mean diameter of lesions was 35.06±20.04 cm² with a mean procedural time 99.9±60.4 min and a mean dissection speed of 9.13±8.13 mm2/min. Technical success with completion of the ESD was 62.2% (112/180) with an overall en-bloc resection rate of 96.4%, while conversion to H-ESD was needed in 37.8% (68/112) of cases with en-bloc resection rate of 32.3%, due to severe fibrosis (38/68), difficult access (17/68), perforation (4/68), hemodynamic instability (2/68). Overall, CR rate was 60.6%, while cR was obtained in 92.3% of cases. No difference between ESD and H-ESD were found in term of neither CR and cR (p=0.725 and p=0.787 respectively). Nine patients (4.8%) were referred for additional surgery due to non-curative histology after endoscopic treatment (adenocarcinomas 11.7% and neuroendocrine carcinomas 1.7%). In total, 24 adverse events (13.3%) occurred, the majority in completed ESD group (20/24 cases), mostly perforations (7%) which were all managed endoscopically. Recurrence occurred in 13 patients (7%) during a mean follow-up period of 374 days (range 55-1808). At the multivariate analysis fibrosis due to previous treatment (OR 3.08 [95 % CI 1.25-7.58], p=0.0243), high grade of fibrosis (OR 2.30 [95 % CI 1.35-3.93], p=0.0021) and right colon location (OR 1.96 [95 % CI 1.48-2.62], p=0.000003) resulted as predictive factors of technical failure.
Conclusion
ESD is a feasible, safe and effective treatment for colorectal-scarred lesion, when performed by expert endoscopists, showing high rates of “en-bloc” resection and assuring high histologic radicality and low rate of recurrence. H-ESD is a viable rescue treatment when the completion of ESD is not feasible.
References
- Azzolini F, Camellini L, Sassatelli R, et al. Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps). Clin Res Hepatol Gastroenterol. 2011;35(8-9):572-579. doi:10.1016/j.clinre.2011.04.013
- Hurlstone DP, Shorthouse AJ, Brown SR, Tiffin N, Cross SS. Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis. Colorectal Dis. 2008;10(9):891-897. doi:10.1111/j.1463-1318.2008.01510.x
- Chedgy FJ, Bhattacharyya R, Kandiah K, Longcroft-Wheaton G, Bhandari P. Knife-assisted snare resection: a novel technique for resection of scarred polyps in the colon. Endoscopy. 2016;48(3):277-280. doi:10.1055/s-0035-1569647
Disclosure
Prof.Silvio Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors declare no conflict of interests.