EFFECTIVENESS OF ENDOSCOPIC RESECTION FOR COLORECTAL LESIONS > 20 MM

Aims Endoscopic removal of large colonic polyps is technically more demanding and should be attempted by experienced endoscopists. Furthermore, larger lesions have higher risk of invasive carcinoma, in which cases, en bloc resection is mandatory to ensure a “curative” endoscopic resection – this can be unfeasible with endoscopic mucosal resection(EMR) or polipectomy. An alternative method is endoscopic submucosal dissection(ESD), which is associated with longer learning curves, longer procedure times and higher complication rates. Our aim is to evaluate the effectiveness and safety of endoscopic resection techniques for the treatment of colonic lesions > 20 mm.

Methods All colonic lesions > 20 mm removed between 2013–2018 in a tertiary center were retrospectively included. Patients with previous colorectal malignancy or surgery were excluded.

Results We included 251 lesions > 20 mm removed by polipectomy/EMR: 97(49%) pedunculated (Ip) and 145(60%) non-pedunculated. Median lesion size was 25 mm (range 20–50 mm). En bloc resection was achieved in 88(90%) of Ip lesions and in 47(32%) of non-pedunculated lesions. Complication rate was 3% (7 cases of delayed bleeding, all managed conservatively/endoscopically). Recurrence rate for fragmented EMR was 13%; ablation of the mucosectomy defect was associated with higher recurrence rate (18vs3%, p < 0.001). Twenty-seven lesions were malignant (12 pedunculated and 15 non-pedunculated). Two Ip lesions were high-risk due to fragmented excision. All non-pedunculated malignant lesions were high-risk; in two of them the only criterium was piecemeal resection.

During the same period, 14 colorectal lesions were removed by ESD (43% hybrid ESD, 64% en bloc). There were 4 high-risk lesions; in 1 the only criterium was piecemeal resection. There was one case of perforation requiring temporary colostomy.

Conclusions In our series, EMR effectively treated 93% of lesions with acceptable complication and recurrence rates; only 2 lesions would have benefited from ESD (ie, 1 out 120). Of the lesions selected for ESD, surgery could have been spared in 1 (7%).