Subscribe to RSS
DOI: 10.1055/a-0650-4562
Risk factors for conversion to snare resection during colorectal endoscopic submucosal dissection in an expert Western center
Publication History
submitted 04 November 2017
accepted after revision 25 May 2018
Publication Date:
11 September 2018 (online)
![](https://www.thieme-connect.de/media/endoscopy/201902/lookinside/thumbnails/16195_10-1055-a-0650-4562-1.jpg)
Abstract
Background There are limited data regarding the risk factors and consequences of conversion to endoscopic mucosal resection (rescue EMR) during colorectal endoscopic submucosal dissection (ESD) in Western centers.
Methods This was a retrospective analysis of a prospectively collected database, from which 225 consecutive ESDs performed between 2013 and 2017 were selected. Of the included patients, 39 (18.6 %) required rescue EMR. Pre- and per-procedure characteristics were evaluated to determine the features associated with the need for rescue EMR. Outcomes and complications were also assessed.
Results 210 patients were included, with median tumor size of 40 mm (range 20 – 110) and most tumors being in a non-rectal location (66.2 %). When compared with full ESD, rescue EMR was significantly associated with lower rates of en bloc resection (43.6 % vs. 100 %) and complete resection (R0 status; 28.2 % vs. 88.9 %), and with a higher rate of recurrence (5.1 % vs. 0 %) and more need for surgery (15.4 % vs. 3.5 %). In multivariable analysis, non-lifting (adjusted odds ratio [ORa] 3.06, 95 % confidence interval [CI] 1.23 – 7.66; P = 0.02), nongranular-type laterally spreading tumor (LST-NG; ORa 2.56, 95 %CI 1.10 – 5.99; P = 0.03), and difficult retroflexion (OR 3.22, 95 %CI 1.01 – 10.28; P = 0.049) were independent risk factors associated with conversion to rescue EMR, while tumor size and location were not.
Conclusions During ESD, the presence of poor lifting, LST-NG morphology, and a difficult retroflexed approach were factors associated with the need to convert to rescue EMR. Conversion to rescue EMR remains a valuable strategy.
-
References
- 1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
- 2 Cao Y, Liao C, Tan A. et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
- 3 Neuhaus H. ESD around the world: Europe. Gastrointest Endosc Clin N Am 2014; 24: 295-311
- 4 Awadie H, Repici A, Bourke MJ. Endoscopic management of large nonpedunculated colorectal polyps: selective treatment algorithms are needed. Endoscopy 2017; 49: 214-216
- 5 Marín-Gabriel JC, Fernández-Esparrach G, Díaz-Tasende J. et al. Colorectal endoscopic submucosal dissection from a Western perspective: Today's promises and future challenges. World J Gastrointest Endosc 2016; 25: 40-55
- 6 Fuccio L, Hassan C, Ponchon T. et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86: 74-86.e17
- 7 Bae JH, Yang DH, Lee S. et al. Optimized hybrid endoscopic submucosal dissection for colorectal tumors: a randomized controlled trial. Gastrointest Endosc 2016; 83: 584-592
- 8 Białek A, Pertkiewicz J, Karpińska K. et al. Treatment of large colorectal neoplasms by endoscopic submucosal dissection: a European single-center study. Eur J Gastroenterol Hepatol 2014; 26: 607-615
- 9 Harris PA, Taylor R, Thielke R. et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377-381
- 10 Saito Y, Otake Y, Sakamoto T. et al. Indications for and technical aspects of colorectal endoscopic submucosal dissection. Gut Liver 2013; 7: 263-269
- 11 Inada Y, Yoshida N, Kugai M. et al. Prediction and treatment of difficult cases in colorectal endoscopic submucosal dissection. Gastroenterol Res Pract 2013; 2013: 523084
- 12 Bae JH, Yang DH, Lee JY. et al. Clinical outcomes of endoscopic submucosal dissection for large colorectal neoplasms: a comparison of protruding and laterally spreading tumors. Surg Endosc 2016; 30: 1619-1628
- 13 Dessain A, Snauwaert C, Baldin P. et al. Endoscopic submucosal dissection specimens in early colorectal cancer: lateral margins, macroscopic techniques, and possible pitfalls. Virchows Arch 2017; 470: 165-174
- 14 Hamilton SR. Bosman FT. Boffetta P. et al. Carcinoma of the colon and rectum. In: Bosman FT, Carneiro F, Hruban RH. et al., eds. WHO classification of tumours of the digestive system. 4th. edn. Lyon: IARC; 2010: 134-142
- 15 Tate DJ, Desomer L, Klein A. et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017; 85: 647-656.e6
- 16 Bartel MJ, Brahmbhatt BS, Wallace MB. Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective. Dig Endosc 2016; 28: 330-341
- 17 Fuccio L, Repici A, Hassan C. et al. Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. Gut DOI: 10.1136/gutjnl-2017-315103.
- 18 Akintoye E, Kumar N, Aihara H. et al. Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis. Endosc Int Open 2016; 4: E1030-E1044
- 19 Yamada M, Saito Y, Takamaru H. et al. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017; 49: 233-242
- 20 Probst A, Ebigbo A, Märkl B. et al. Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center. Endoscopy 2017; 49: 222-232
- 21 Repici A, Hassan C, Pagano N. et al. High efficacy of endoscopic submucosal dissection for rectal laterally spreading tumors larger than 3 cm. Gastrointest Endosc 2013; 77: 96-101
- 22 Farhat S, Chaussade S, Ponchon T. et al. Endoscopic submucosal dissection in a European setting. A multi-institutional report of a technique in development. Endoscopy 2011; 43: 664-670
- 23 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65: 806-820
- 24 Arezzo A, Passera R, Saito Y. et al. Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions. Surg Endosc 2014; 28: 427-438
- 25 Yang DH, Kwak MS, Park SH. et al. Endoscopic mucosal resection with circumferential mucosal incision for colorectal neoplasms: comparison with endoscopic submucosal dissection and between two endoscopists with different experiences. Clin Endosc 2017; 50: 379-387
- 26 Okamoto K, Muguruma N, Kagemoto K. et al. Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases. Dig Endosc 2017; 29 (Suppl. 02) 45-52
- 27 Toyonaga T, Man-I M, Morita Y. et al. Endoscopic submucosal dissection (ESD) versus simplified/hybrid ESD. Gastrointest Endosc Clin N Am 2014; 24: 191-199
- 28 Terasaki M, Tanaka S, Oka S. et al. Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm. J Gastroenterol Hepatol 2012; 27: 734-740
- 29 Byeon JS, Yang DH, Kim KJ. et al. Endoscopic submucosal dissection with or without snaring for colorectal neoplasms. Gastrointest Endosc 2011; 74: 1075-1083
- 30 Hori K, Uraoka T, Harada K. et al. Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum. Endoscopy 2014; 46: 862-870
- 31 Takeuchi Y, Iishi H, Tanaka S. et al. Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort. Int J Colorectal Dis 2014; 29: 1275-1284
- 32 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
- 33 Imai K, Hotta K, Yamaguchi Y. et al. Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training. Gastrointest Endosc 2016; 83: 954-962
- 34 Iacopini F, Saito Y, Bella A. et al. Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty. Endosc Int Open 2017; 5: E839-E846
- 35 Barret M, Lepilliez V, Coumaros D. et al. The expansion of endoscopic submucosal dissection in France: A prospective nationwide survey. United European Gastroenterol J 2017; 5: 45-53