Introduction
Colorectal endoscopic submucosal dissection (ESD) is not widely performed in western countries due to technical complexity, risk of adverse events, and procedure time. Hybrid ESD (H-ESD) - partial submucosal dissection followed by snare-assisted resection – may be useful to achieved endoscopic resection in difficult situations. In our center we use H-ESD as rescue therapy during conventional ESD in case of unstable position, inability to achieving appropriate and safe knife angle, advanced submucosal fibrosis or thin submucosal layer and patient instability.
Aims & Methods
We retrospectively analyzed colorectal ESD performed in our centre between January 2014 and March 2023, colorectal lesions in inflammatory bowel diseases were excluded. Univariate and multivariate analyses were conducted to examine factors that may have influenced switch to H-ESD.
Results
A total of 281 colorectal ESDs for superficial neoplasms in 276 patients were considered. 160 patients (58%) were male with an average age of 68,9 years. In 55 (19,6%) cases ESD was switch to H-ESD.. 171 lesions were located in the colon (60.8 %) and 110 (39.1%) in the rectum; mean maximum diameter of the neoplasms was 35,9 mm (SD 18,4 mm). En bloc resection and complete resection (en bloc resection and R0) were achieved in 259 (92 %) and 245 (86 %) cases respectively.
On univariate analysis, the use of waterjet system-assisted knife (OR 0,3; 95% CI 0,17-0,57), underwater-ESD (OR 0,24; 95% CI 0,09-0,63), rectal localization (OR 0,17; 95% CI 0,07-0,40) and granular laterally spreading morphology (OR 0,40; 95% CI 0,21-0,75) were significantly associated to the achievement of complete ESD. Proximal colon localization (OR 3,9; 95% CI 2,08-7,30), severe submucosal fibrosis (OR 4,9; 95% CI 2,51-9,63), non-granular laterally spreading morphology (OR 2,31; 95% CI 1,27-4,21) and maximum diameter < 40 mm (OR 3,91; 95% CI 1,83-8,38) were related to the switch to H-ESD. On multivariate analysis only waterjet system-assisted knife use and U-ESD were significantly correlated with achievement of complete ESD; severe submucosal fibrosis and proximal colon localization resulted significantly related to the switch to H-ESD.
| Univariate Logistic Regression | Multivariate Logistic Regression |
|
| VARIABLE | OR | CI | P | OR | CI | P |
| Proximal colon | 3,90 | 2,08-7,30 | <0,0001 | 3,0481 | 1,21-7,68 | 0,0181 |
| Rectum | 0,17 | 0,07-0,40 | <0,0001 | 0,3956 | 0,13- 1,21 | 0,1048 |
| LST NG | 2,31 | 1,27-4,21 | 0,0061 | 0,6277 | 0,22-1,78 | 0,3812 |
| LST G | 0,40 | 0,21-0,75 | 0,0039 | 0,4494 | 0,15-1,32 | 0,1452 |
| Maximum diameter < 40 mm | 3,91 | 1,83-8,38 | 0,0004 | 1,9589 | 0,81-4,76 | 0,1378 |
| Severe submucosal fibrosis (F2) | 4,91 | 2,52-9,63 | <0,0001 | 4,6588 | 2,10-9,88 | 0,0001 |
| Waterjet system-assisted knife | 0,30 | 0,17-0,57 | 0,0002 | 0,4297 | 0,21-0,88 | 0,0219 |
| Underwater ESD | 0,24 | 0,09-0,64 | 0,0039 | 0,1612 | 0,06-0,47 | 0,0008 |
Conclusion
The use of waterjet system-assisted knife and underwater technique reduce the need to switch to H-ESD during endoscopic submucosal dissection of superficial colorectal lesions. Severe submucosal fibrosis and proximal location are risk factors for the need for the H-ESD switch.