Risk factors for conversion to snare resection during colorectal endoscopic submucosal dissection in an expert Western center

Enrique Pérez-Cuadrado-Robles; Christophe Snauwaert; Tom G. Moreels; Anne Jouret-Mourin; Pierre H. Deprez; Hubert Piessevaux

doi:10.1055/a-0650-4562

Endoscopy, Table of Contents

Endoscopy 2019; 51(02): 152-160
DOI: 10.1055/a-0650-4562

Original article

Risk factors for conversion to snare resection during colorectal endoscopic submucosal dissection in an expert Western center

Enrique Pérez-Cuadrado-Robles

¹Department of Hepatogastroenterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

,

Christophe Snauwaert

¹Department of Hepatogastroenterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

,

Tom G. Moreels

¹Department of Hepatogastroenterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

,

Anne Jouret-Mourin

²Department of Pathology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

,

Pierre H. Deprez

¹Department of Hepatogastroenterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

,

Hubert Piessevaux

¹Department of Hepatogastroenterology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

› Author Affiliations

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 [OR^a] 3.06, 95 % confidence interval [CI] 1.23 – 7.66; P = 0.02), nongranular-type laterally spreading tumor (LST-NG; OR^a 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.

Full Text

References

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
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