Endoscopic mucosal resection for advanced sessile adenoma and early-stage colorectal carcinoma

Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos)

BACKGROUND AND AIMS

Piecemeal EMR of colorectal laterally spreading tumors (LSTs) >20 mm is effective. Experience is limited in the use of cap-assisted EMR (EMR-C) for resection of colonic lesions. We compared the efficacy and the safety of EMR-C for the removal of colonic LSTs ≥30 mm with "inject-and-cut" standard EMR (EMR-S).

METHODS

In this randomized trial from 4 Italian centers, 138 patients were treated with EMR-C and 102 with EMR-S. The rates of residual lesions, percentage of recurrence after 12 months, and adverse events were evaluated.

RESULTS

One hundred forty-three lesions were resected with EMR-C and 102 with EMR-S. Argon plasma coagulation (APC) was used as adjunctive treatment in 2.9% of EMR-Cs and in 22.5% of EMR-Ss (P < .001). The median time required was 20 minutes for EMR-C and 30 minutes for EMR-S (P < .001). Adverse events (AEs) occurred in 14 EMR-Cs (10.1%; 2 perforations, 11 bleeding events, and 1 stenosis) and in 22 EMR-Ss (21.6%; 1 perforation and 21 bleeding events) (P = .017). Intraprocedural AEs occurred in 3.6% of EMR-Cs and 16.7% of EMR-Ss (P = .001). Overall, residual lesions within 12 months were found to be significantly higher with EMR-S (32 patients, 31.4%) than with EMR-C (8 patients, 5.8%) (P < .001). Recurrence at follow-up colonoscopy in 12 months occurred in 7 EMR-Cs (5.1%) and 17 EMR-Ss (16.7%; P < .001).

CONCLUSIONS

The study demonstrated the feasibility and safety of EMR-C for removing large colorectal LSTs, with higher eradication rates, shorter resection time, and less use of APC when compared with EMR-S. (Clinical trial registration number: NCT03498664.).

Functionalized layer-by-layer assembled film with directional 5-fluorouracil release to target colon cancer

The objective of this work was to prepare and characterize pH-sensitive capsule containing functionalized layer-by-layer (LbL) assembled polymeric film with directional drug release and evaluate its effectiveness against colon cancer. 5-Fluorouracil (5FU) loaded LbL film was prepared by sequential adsorption of chitosan and alginate polyelectrolytes. This LbL film was coated with polycaprolactone (PCL, 95% w/w) as a backing layer to restrict 5FU release on one-side. The other side constituted the folic acid conjugated chitosan layer for cancer targeting. This film was encapsulated into a gelatin capsule coated with pH-sensitive Eudragit S100. 5FU loaded LbL film was characterized for physical and mechanical properties. Mucoadhesion studies performed using excised rabbit colon showed that chitosan-side of LbL film adhered with significantly (p < 0.05) greater strength compared with PCL-side. Non-everted rat colon-sac model and open colon membrane model studies showed greater permeation of 5FU across the colon wall when adhered to chitosan-side of LbL film compared with PCL-side of the film. Cell monolayer and 3D-spheroid model studies using Caco-2 and COLO 320DM colorectal cancer cells showed significant (p < 0.05) growth inhibition by 5FU loaded LbL film compared with free 5FU solution. In conclusion, pH-sensitive capsule containing 5FU loaded LbL film can be developed to target colorectal cancer for regional drug delivery.

Clinical and financial impacts of introducing an endoscopic mucosal resection service for treatment of patients with large colonic polyps into a regional tertiary hospital

Background and study aims  Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods  Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 - 2008) and 9 years after its introduction (2009 - 2017). Results  From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P  < 0.0001), and shorter average LoS (1 vs 9 days, P  < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions  The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.

Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery

BACKGROUND

Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up.

METHOD

Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence.

RESULTS

TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis.

CONCLUSION

TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.

Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review

AIM

To assess the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for the treatment of colorectal lesions.

METHODS

A literature search was conducted from January 2000 to May 2015. The main outcomes were: recurrence after "en bloc" and "piecemeal" resection; procedure related adverse events; the EMR endoscopic success rate and the completely eradicated resection rate (R0) after ESD.

RESULTS

A total of 66 studies were included in the analysis. The total number of lesions was 17950 (EMR: 11.873; ESD: 6077). Recurrence rate was higher in the EMR than ESD group (765/7303l vs. 50/3910 OR 8.19, 95% CI 6.2-10.9 p<0.0001). EMR-en bloc resection was achieved in 6793/10803 lesions (62.8%) while ESD-en bloc resection was obtained in 5500/6077 lesions (90.5%) (OR 0.18, p<0.0001, 95% CI 0.16-0.2). Perforation occurred more frequently in ESD than in EMR group (p<0.0001, OR 0.19, 95% CI 0.15-0.24).

CONCLUSIONS

Endoscopic resection of large colorectal lesions is safe and effective. Compared with EMR, ESD results in higher "en bloc" resection rate and lower local recurrence rate, however ESD has high procedure-related complication rates.

Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective

Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non-invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high-risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.

Outcome and risk of recurrence for endoscopic resection of colonic superficial neoplastic lesions over 2 cm in diameter

BACKGROUND

Large colorectal superficial neoplastic lesions are challenging to remove. This study aimed to assess the outcomes of routine endoscopic resection of large (≥2 cm and <3 cm) and giant (≥3 cm) lesions.

METHODS

From 4587 endoscopic resections, 265 (5.7%) large and giant lesions were removed in 249 patients. We retrospectively analyzed 125 patients (141 endoscopic mucosal resection, 73 large and 68 giant lesions) with a follow-up of 6-12 months. Rate of en bloc and piecemeal resection, recurrence and risk factors were analyzed.

RESULTS

En bloc was performed in 92 cases (65.2%) and piecemeal resection in 49 (34.8%). A complete endoscopic resection was achieved in 139 cases (98.5%) with radical resection in 84/139 cases (60.4%). Argon plasma coagulation was applied in 18/141 lesions (12.8%). A recurrence occurred in 16/139 lesions (11.5%). The risk of recurrence at one year was significantly higher for giant than large lesions (p=0.03). The recurrence risk was higher in treated than in non-argon plasma coagulation treated lesions (p=0.01).

CONCLUSIONS

endoscopic mucosal resection is a safe and effective routine treatment for large superficial neoplastic lesions. The risk factors for recurrence include giant size, non-protruding morphology, piecemeal technique and argon plasma coagulation.

Use of a double-channel gastroscope reduces procedural time in large left-sided colonic endoscopic mucosal resections

Background/Aims

Endoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area.

Methods

All EMRs for sessile or flat rectosigmoid lesions ≥2 cm performed between July 2011 and September 2012 were retrospectively analyzed.

Results

There were 55 lesions ≥2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4±18.3 minutes vs. 36.3±24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33±21 minutes vs. 58.7±20.6 minutes, p=0.004).

Conclusions

Our data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection

BACKGROUND

EMR and endoscopic submucosal dissection (ESD) are used frequently to remove colon neoplasms. However, the predominance of these procedures has not yet been thoroughly explored.

OBJECTIVE

To compare the efficacy and adverse events related to EMR with those related to ESD for colon neoplasms.

DESIGN

A meta-analysis of 8 studies published between 2005 and 2013.

SETTING

Multicenter review.

PATIENTS

Patients from 8 studies yielding 2299 lesions.

INTERVENTIONS

EMR or ESD.

MAIN OUTCOME MEASUREMENTS

En bloc resection, curative resection, recurrence, and adverse events.

RESULTS

The pooled odds ratios (OR) (OR [95% confidence interval]) for the tumor size, length of the procedure, en bloc resection, curative resection, recurrence, additional surgery, delayed bleeding, and perforation by ESD versus EMR were 7.38 (6.42-8.34), 58.07 (36.27-79.88), 6.84 (3.30-14.18), 4.26 (3.77-6.57), 0.08 (0.04-0.17), 2.16 (1.16-4.03), 0.85 (0.45-1.60), and 4.96 (2.79-8.85), respectively.

LIMITATIONS

This analysis included only nonrandomized studies.

CONCLUSION

The size of the tumor and rate of en bloc resection and curative resection were higher, and the rate of recurrence was lower in the ESD group versus the EMR group. However, in the ESD group, the procedure was longer, and the rate of additional surgery and perforation was higher, suggesting that the indications for ESD should therefore be rigorously determined in order to avoid such problems.

Feasibility of endoscopic resection for sessile nonampullary duodenal tumors: a multicenter retrospective study

Objectives. Sessile nonampullary duodenal tumors (SNADTs) are relatively rare and endoscopic resection of these lesions is considered more challenging than in other parts of the gastrointestinal tract. The aim of this study was to evaluate the feasibility of endoscopic resection for SNADT. Methods. Medical records including endoscopic resection for SNADT from July 2002 to July 2013 from 5 centers affiliated to The Catholic University of Korea were reviewed retrospectively. Demographic features and clinical outcomes such as complete resection and complications were analyzed. Results. A total of 56 lesions from 54 patients were enrolled in this study. Forty-five lesions were resected by endoscopic mucosal resection (EMR), 6 lesions by endoscopic submucosal dissection (ESD), and 5 lesions by simple polypectomy. Histologic examination after endoscopic resection revealed adenocarcinoma in 2, low grade adenoma in 25, high grade adenoma in 11, and carcinoid tumor in 18 lesions. En bloc resection rates and histological complete resection rates were 78.6% (44/56) and 80.0% (28/35), respectively. Bleeding which required additional endoscopic intervention occurred in 1.8% (1/56) and perforation in 7.1% (4/56). There was no procedure-related mortality. Conclusions. Endoscopic resection techniques including ESD might be safe and effective modalities for the management of SNADT.

Transanal endoscopic surgery with total wall excision is required with rectal adenomas due to the high frequency of adenocarcinoma

BACKGROUND

Colorectal adenomatous polyps are considered premalignant lesions, although a high percentage are already malignant at the time of their removal. Full-thickness excision in patients with adenoma detected in preoperative biopsy enables much more accurate pathology examination and has shown that local surgery is appropriate for T1 adenocarcinoma.

OBJECTIVE

To determine whether full-thickness excision during transanal endoscopic surgery is the treatment of choice for rectal adenoma, and to identify possible predictors of invasive adenocarcinoma associated with this type of lesion.

DESIGN

Prospective, observational study.

SETTING

The study was conducted at a university teaching hospital.

PATIENTS

All patients scheduled for transanal endoscopic surgery after detection of adenoma in a preoperative biopsy between June 2004 and February 2013 entered the study.

MAIN OUTCOME MEASURES

The principal variable was the presence of invasive adenocarcinoma in the pathology study. Other study variables were the epidemiological variables sex and age; the clinical variables tumor size, number of quadrants affected, distance from the anal verge, and tumor location; and the morphological variables tumor aspect, degree of dysplasia, preoperative biopsy (tubulo-villous), endorectal ultrasound, and pelvic MRI stage. Variables found to be related to the risk of malignancy in rectal adenomas were evaluated using univariate and multivariate analysis.

RESULTS

Of 471 patients who underwent surgery, 277 had a preoperative diagnosis of adenoma. Final pathology studies showed 52 (18.8%) invasive adenocarcinomas, among which 27 were pT1 (52%), 16 pT2 (30.7%), and 9 pT3 (17.3%). Factors predictive of invasive adenocarcinoma were sessile morphology (OR 3.2, 95%CI 1.4-7.1), high-grade dysplasia (OR 2.3, 95%CI 1.2-4.8), and endorectal ultrasound stage uT2-T3 (OR 3.8, 95%CI 1.6-9).

LIMITATIONS

The limitations are derived from the observational design.

CONCLUSIONS

In this sample, half of the adenocarcinomas from adenomas were T1 adenocarcinomas. Because a high proportion of rectal adenomas are, in fact, invasive adenocarcinomas, full-thickness excision is appropriate.

Endoscopic resection as the first-line treatment for early colorectal cancer: comparison with surgery

INTRODUCTION

Endoscopic resection has emerged as an alternative therapeutic option for selected cases of early colorectal cancer. However, even now, few data are available on the comparative effectiveness of endoscopic versus surgical resection of early colorectal cancer. The aim of our study was to compare the clinical outcomes in patients with early colorectal cancer who underwent endoscopic resection and those who underwent surgical resection.

METHODS

292 early colorectal cancer lesions in 287 patients who were treated with either endoscopic resection or colorectal surgery (open or laparoscopic colorectal resection) between January 2005 and December 2010 were retrospectively analyzed. After excluding 54 deep submucosal lesions [and/or tumor budding (Grade 2 or 3)], a total of 168 lesions with mucosal/superficial submucosal invasion were treated by endoscopic resection, and 70 lesions with mucosal/superficial submucosal invasion were treated by colorectal surgery.

RESULTS

In the endoscopic resection group, the en bloc resection rate and the complete resection rate were 91.1 and 91.1%, respectively. In the colorectal surgery group, both the en bloc resection rate and the curative resection rate were 100%. However, using Log rank test in Kaplan-Meier curve, no significant difference in recurrence rate (including metachronous cancer) during the median follow-up period of 37 months (range, 6-98 months) was observed between the two groups (p = 0.647). In addition, a similar morbidity rate was observed for endoscopic resection compared with surgery (5.4 vs. 5.7%, p = 0.760). A significantly shorter hospital stay was observed in the endoscopic resection group than colorectal surgery group [median 2 days (range, 2-29) vs. median 10 days (range, 7-37), p < 0.001).

CONCLUSION

We suggest that endoscopic resection, being equally effective but less invasive than surgery, can be the first-line treatment for well selected early colorectal cancer.

A prospective comparative study of blended and pure coagulation current in endoscopic mucosal resection of large sessile colorectal polyps

BACKGROUND

The aim of this study was to compare pure coagulation and blended current in the resection of large colorectal sessile polyps (SPs).

PATIENTS AND METHODS

Between January 2009 and June 2012, 84 patients (45 men, 39 women; median age 66 y; range, 42 to 88 y) with large colorectal SPs (diameter ≥2 cm) were randomized in 1:1 ratio to undergo treatment by the "lift and cut" piecemeal resection technique. A total of 43 blended current subjects (group A) were well matched to 41 pure coagulation current subjects (group B), with a median lesion size of 3.9 cm (group A, 3.7 vs. group B, 4.2 cm; P=0.316), respectively. The rate of complications, the factors that predict complications, and the recurrence of adenoma were analyzed.

RESULTS

Complete macroscopic resection was achieved in 39 patients (90.7%) of group A and in 36 patients (87.6%) of group B (P=0.735). Argon plasma coagulation at resection's margins was performed in 10 patients (23.2%) of group A and in 14 patients (34.1%) of group B (P=0.269). Eight patients (9.5%) [group A, n=3 patients (7.1%) vs. group B, n=5 patients (12%); P=0.756] developed immediate (4) or delayed (4) bleeding. Four patients with bleeding were under treatment with selective serotonin reuptake inhibitors. All bleedings were successfully treated conservatively or with endoclipping and heater probe application. Perforation occurred in 1 patient of each group and was managed by clips closure and antibiotics and right hemicolectomy, respectively. Postpolypectomy syndrome was observed in 2 patients (4.6%) of group A and 3 patients (7.3%) of group B (P=0.834). In 3 patients, the histopathologic analysis of resected SPs revealed invasive carcinoma, and surgical resection was performed in 1 patient. Two patients refused operation. Among the patients who underwent follow-up surveillance colonoscopy, a total recurrence rate of 25.67% of adenomas with no difference was observed between the 2 groups [group A, n=8 patients (21.6%) vs. group B, n=11 patients (31.4%); P=0.345]. Recurrence of adenoma was observed in 12 patients (16.22%) without and in 7 patients (9.46%) with argon plasma coagulation treatment.

CONCLUSIONS

No difference was found in the rate of complications between the 2 types of current used in the resection of large colorectal SPs. However, an influence of selective serotonin reuptake inhibitors on postpolypectomy bleeding was observed, which deserves further investigation.

Oncologic colorectal resection after endoscopic treatment of malignant polyps: does endoscopy have an adverse effect on oncologic and surgical outcomes?

BACKGROUND

Early colorectal cancer is increasingly treated by endoscopic removal. In cases of incomplete resection or high-risk carcinoma, additional surgery is necessary.

OBJECTIVE

To evaluate the frequency of subsequent oncologic surgery after endoscopic resection of colorectal cancer, the rate of lymph node metastasis, residual cancer, and morbidity and mortality rates of the operation. Any eventual adverse effect of the prior endoscopic therapy on the surgical and oncologic outcome was assessed.

DESIGN

Retrospective review of prospectively collected data.

SETTING

University hospital.

PATIENTS

Sixty-six consecutive patients with incomplete endoscopic treatment and need for additional surgery between 2004 and 2011.

INTERVENTION

The data of these patients were compared with those of a group of patients with surgery for early colorectal cancer during the same period without prior endoscopic resection as the control group.

MAIN OUTCOME MEASUREMENTS

Rate of lymph node metastasis and residual cancer, perioperative morbidity and mortality.

RESULTS

The lymph node metastasis rate after oncologic resection was 8.6%, and the residual cancer rate was 41%. Risk factors for residual cancer were macroscopic incomplete resection (P < .0001), positive resection margins (P = .03), and piecemeal resection (P = .004). No mortality was observed. Perioperative morbidity, mortality, and oncologic outcome were not significantly different in the group with prior endoscopic resection compared with the primarily operated group.

LIMITATIONS

Retrospective study.

CONCLUSION

Endoscopic treatment of malignant polyps does not worsen surgical and oncologic outcomes in cases of subsequent surgery. Because mortality and morbidity are low, oncologic resection generally should be done in the presence of risk factors for residual cancer.

Use of prototype two-channel endoscope with elevator enables larger lift-and-snare endoscopic mucosal resection in a porcine model

Background: Flat and depressed lesions are becoming increasingly recognized in the esophagus, stomach, and colon. Various techniques have been described for endoscopic mucosal resection (EMR) of these lesions.

Aims: To evaluate the efficacy of lift-grasp-cut EMR using a prototype dual-channel forward-viewing endoscope with an instrument elevator in one accessory channel (dual-channel elevator scope) as compared to standard dual-channel endoscopes.

Methods: EMR was performed using a lift-grasp-cut technique on normal flat rectosigmoid or gastric mucosa in live porcine models after submucosal injection of 4 mL of saline using a dual-channel elevator scope or a standard dual-channel endoscope. With the dual-channel elevator scope, the elevator was used to attain further lifting of the mucosa. The primary endpoint was size of the EMR specimen and the secondary endpoint was number of complications.

Results: Twelve experiments were performed (six gastric and six colonic). Mean specimen diameter was 2.27 cm with the dual-channel elevator scope and 1.34 cm with the dual-channel endoscope (P = 0.018). Two colonic perforations occurred with the dual-channel endoscope, vs no complications with the dual-channel elevator scope.

Conclusions: The increased lift of the mucosal epithelium, through use of the dual-channel elevator scope, allows for larger EMR when using a lift-grasp-cut technique. Noting the thin nature of the porcine colonic wall, use of the elevator may also make this technique safer.

Clinical outcomes and direct costings of endoluminal clipping compared to surgery in the management of iatrogenic colonic perforation

OBJECTIVE

To compare the outcomes and costs of endoluminal clipping and surgery in the management of iatrogenic colonic perforation.

METHODS

A retrospective, single-center, clinical and economic analysis of outcomes and costings between endoluminal clipping and surgery in consecutive cases of iatrogenic colonic perforations was conducted.

RESULTS

In total, 7136 colonoscopies performed over a 6-year period were complicated by 12 (0.17%) perforations. Seven cases were treated by endoscopic clipping (with a success rate of 71.4%) and five with immediate surgery. Both groups of patients had similar clinical and individual characteristics. Patients who were treated with endoscopic clipping had a shorter period of hospitalization (median 9 vs 13 days) compared to surgery, but this was not statistically significant. Compared to patients who had immediate surgery, the median direct health-care costs for all procedures (US$ 115.10 vs US$ 1479.50, P = 0.012) and investigations (US$ 124.60 vs US$ 512.90, P = 0.048) during inpatient stay were lower for the endoscopic clipping group. There was a trend towards a lower overall inpatient median cost for patients managed with endoscopic clipping compared to surgery (US$ 1481.70 vs US$ 3281.90, P = 0.073).

CONCLUSION

Endoluminal clipping may be more cost-effective than surgery in the management of iatrogenic colonic perforations.

Endoscopic mucosal resection in high- and low-volume centers: a prospective multicentric study

BACKGROUND

Endoscopic mucosal resection (EMR) is an effective therapeutic technique well-standardized worldwide for the treatment of gastrointestinal neoplasm limited to the mucosal layer. To date, no study has compared technical and clinical differences based on the number of EMRs performed per year. This study aimed to compare EMR technical success, complications, and clinical outcome between low-volume centers (LVCs) and high-volume centers (HVCs). A total of nine endoscopic centers were included in the study.

METHODS

This prospective study investigated consecutive patients with sessile polyps or flat colorectal lesions 1 cm or larger referred for EMR.

RESULTS

A total of 427 lesions were resected in 384 patients at nine endoscopic centers. Males accounted for 60.4% and females for 39.6% of the patients. Most of the EMRs (84.8%) were performed in HVCs and only 15.2% in LVCs. All the lesions were resected in only one session. Argon plasma coagulation was performed on the margins of piecemeal resection in 15.7% of the patients in HVCs only. Complete excision was achieved for 98.6% of the lesions in HVCs and 98.8% of the lesions in LVCs. The complication rate was 4.4% in HVCs and 4.6% in LVCs (p = 0.94). Delayed bleeding occurred in 2.5% of the HVC cases and 3.1% of the LVC cases. Perforation occurred in 1.9% of the HVC cases and 1.5% of the LVC cases (p = 1.00). Recurrences were experienced with 15% of the lesions: 15.5% in HVCs and 14% in LVCs (p = 0.79).

CONCLUSIONS

The study showed that EMR can be performed also in LVC.

Follow up after endoscopic resection in submucosal invasive colorectal cancers

Submucosal invasive colorectal cancers (SM-CRC) have approximately a 10% chance of lymph node metastasis, which requires surgical resection including lymph node dissection for curative treatment. It is important to optimally survey patients after curative resection for SM-CRC in order to detect early recurrence. In the present report, we principally show the long-term outcomes after follow up of SM-CRC resected endoscopically based on a report of the literature and our experience in Japan. The long-term outcomes of low-risk SM-CRC endoscopically resected alone or high-risk SM-CRC with additional surgical resection with lymph node dissection are excellent. However, the risk of local recurrence of endoscopic resection alone in patients with high-risk submucosal invasive cancer was significantly higher in rectal cancer as compared to similar colonic cancer. Patients with submucosal rectal cancer showing high-risk pathological features are, therefore, strongly recommended to undergo additional treatment. We consider that longer follow up is required for patients with SM-CRC because recurrence occurred relatively later in SM-CRC compared to advanced colorectal cancer.

Long-term outcomes after resection for submucosal invasive colorectal cancers

BACKGROUND & AIMS

Little is known about the long-term outcomes of patients with submucosal invasive colorectal cancer who undergo endoscopic or surgical resection. We performed a retrospective analysis of long-term outcomes of patients treated for submucosal colon and rectal cancer.

METHODS

We collected data on 549 patients with submucosal colon cancer and 209 patients with submucosal rectal cancer who underwent endoscopic or surgical resection at 6 institutions over a median follow-up period of 60.5 months. Patients were classified into one of 3 groups: low-risk patients undergoing only endoscopic resection (group A), high-risk patients undergoing only endoscopic resection (group B), and high-risk patients undergoing surgical resection that included lymph node dissection (group C). We assessed recurrence rates, 5-year disease-free survival, and 5-year overall survival. Cox regression analysis was used to compare recurrences.

RESULTS

The rates of recurrence, disease-free survival, and overall survival in group A for submucosal colon and rectal cancer were 0% versus 6.3% (P < .05), 96% versus 90%, and 96% versus 89%, respectively. For group B, these values were 1.4% versus 16.2% (P < .01), 96% versus 77% (P < .01), and 98% versus 96%, respectively; local recurrence was observed in 5 patients (one with submucosal colon cancer and 4 with submucosal rectal cancer). Tumor location was the only factor that contributed significantly to disease recurrence and death (hazard ratio, 6.73; P = .045). For group C, these values were 1.9% versus 4.5%, 97% versus 95%, and 99% versus 97%, respectively.

CONCLUSIONS

The risk for local recurrence was significantly higher in high-risk patients with submucosal rectal cancer than in patients with submucosal colon cancer when treated with only endoscopic resection. The addition of surgery is therefore recommended for patients with submucosal rectal cancer with pathologic features indicating a high risk of tumor progression; University Hospital Medical Network Clinical Trials Registry, Number: UMIN 000008635.

Warning for unprincipled colorectal endoscopic submucosal dissection: accurate diagnosis and reasonable treatment strategy

Piecemeal endoscopic mucosal resection (EMR) is generally indicated for laterally spreading tumors (LST) >2 cm in diameter. However, the segmentation of adenomatous parts does not affect the histopathological diagnosis and completeness of cure. Thus, possible indications for piecemeal EMR are both adenomatous homogenous-type granular-type LST (LST-G) and LST-G as carcinoma in adenoma without segmentalizing the carcinomatous part. Diagnosis of the pit pattern using magnifying endoscopy is essential for determining the correct treatment and setting segmentation borders. In contrast, endoscopic submucosal dissection (ESD) is indicated for lesions requiring endoscopic en bloc excision, as it is difficult to use the snare technique for en bloc excisions such as in non-granular-type LST (LST-NG), especially for the pseudodepressed type, tumors with a type VI pit pattern, shallow invasive submucosal carcinoma, largedepressed tumors and large elevated lesions, which are often malignant (e.g. nodular mixed-type LST-G). Other lesions, such as intramucosal tumor accompanied by submucosal fibrosis, induced by biopsy or peristalsis of the lesion; sporadic localized tumors that occur due to chronic inflammation, including ulcerative colitis; and local residual early carcinoma after endoscopic treatment, are also indications for ESD. In clinical practice, an efficient endoscopic treatment with segregation of ESD from piecemeal EMR should be carried out after a comprehensive evaluation of the completeness of cure, safety, clinical simplicity, and cost-benefit, based on an accurate preoperative diagnosis.

Does endoscopic mucosal resection for large colorectal polyps allow ambulatory management?

BACKGROUND

Endoscopic mucosal resection (EMR) is an efficacious endoscopic therapy for large adenoma or confined neoplasia. The most frequent complication is delayed hemorrhage, and hemoclips appear to be an effective therapeutic option. The aim of this study was to determine if large EMR could allow ambulatory management.

METHODS

Colorectal polyps ≥20 mm in size treated by EMR in one endoscopy unit were prospectively included. The period from September 2007 to September 2008 was considered as the reference period (period 1). From September 2008 on, patients were hospitalized in an ambulatory unit. Periods from September 2008 to September 2009 (period 2), from September 2009 to September 2010 (period 3), and from September 2010 to September 2011 (period 4) were compared to the reference period. Patients receiving anticoagulation drugs were excluded from the study.

RESULTS

A total of 138 patients were treated by 139 EMRs for large colorectal polyps. EMRs were completed by at least one clip per centimeter in 10.7 %, 30.2 % (p = NS), 50 % (p = 0.015), and 76 % (p = 0.001). Ambulatory EMRs were performed in 21 %, 52.4 % (p = 0.008), 67.6 % (p = 0.02), and 88.2 % (p = 0.004) of cases during periods 1, 2, 3, and 4. The complication rate was stable during the four periods. No patients with more than one hemoclip per EMR centimeter experienced delayed bleeding.

CONCLUSIONS

The low complication rate during the four periods allows us to consider ambulatory EMR for large colorectal lesions ≥20 mm in diameter as an option. One hemoclip per centimeter may help prevent delayed hemorrhage in patients without anticoagulation drugs.

Endoscopic ablation therapy for gastrointestinal superficial neoplasia

AIM

  In Japan, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely accepted and standardized for the treatment of gastrointestinal superficial neoplasia.

METHODS

  In contrast, mucosal ablation techniques are more common in Western countries and a variety of endoscopic ablation modalities, including argon plasma coagulation (APC), photodynamic therapy (PDT) and lasers, are used.

RESULTS

  Recently developed modalities such as radiofrequency ablation (RFA) and cryotherapy are also available for the treatment of superficial lesions such as dysplasia of Barrett's esophagus.

CONCLUSION

  Although we should understand that the completeness of destruction of neoplastic tissue can only be judged at follow up, endoscopic ablation is a viable alternative to endoscopic resection for dysplasia and early-stage malignancies, especially for poor candidates of surgery or endoscopic resection.

Evaluation of patient satisfaction of an outpatient colonoscopy service in an asian tertiary care hospital

Aim. To evaluate patient satisfaction towards an outpatient colonoscopy service and analyze areas of dissatisfaction for potential improvement. Method. Consecutive patients attending the outpatient diagnostic colonoscopy service in University of Malaya Medical Centre between 1st February and 31th July 2010 were interviewed using a questionnaire modified from the modified Group Health Association of America-9 (mGHAA-9) questionnaire. Favorable/unfavorable responses to each question, contribution of each question to unfavorable responses, and effect of waiting times on favorable/unfavorable response rates were analyzed. Results. Interview was carried out on 426 patients (52.1% men). Mean age ± standard deviation was 61.3 ± 12.9 years old. Mean waiting times for colonoscopy appointment and on colonoscopy day were 3.8 ± 2.7 months and 1.1 ± 0.8 hours, respectively. The main factors that contributed to unfavorable responses were bowel preparation followed by waiting times for colonoscopy appointment and on colonoscopy day (32.3%, 27.5%, and 19.6%, resp.). Favorable responses diminished to undesirable levels when waiting times for colonoscopy appointment and on colonoscopy day exceeded 1 month and 1 hour, respectively. Conclusion. Bowel preparation and waiting times were main factors for patient dissatisfaction. Waiting times for colonoscopy appointment and on colonoscopy day should not exceed 1 month and 1 hour, respectively, to maintain acceptable levels of patient satisfaction.

Management of local rectal cancer: evidence, controversies and future perspectives in radiotherapy

SUMMARY Rectal cancer comprises approximately 25% of all primary colorectal cancers. The optimal diagnostic and treatment approach for this heterogeneous malignancy is still contentious, and improvements in general multidisciplinary management are required. During recent years a number of randomized studies led by European investigators have shown optimization in preoperative staging, improvements in surgical technique and the histopathological assessment of the resected specimen, and the benefit of combined modality treatment. The main recommendations and the trends in research on radiotherapy and integrated treatments will be summarized with an overview on some relevant points about imaging and pathological staging.

[Endoscopic mucosal resection of colorectal tumors--our first experience]

BACKGROUND/AIM

Endoscopic mucosal resection (EMR) or mucosectomy is an interventional procedure for minimal invasive endoscopic removal of benign and malignant digestive tract tumors. Mucosectomy removes flat and sessile neoplasms, early colorectal cancer (CRC) confined to mucosa or submucosa and lateral spreading tumors. The aim of the study was to show our first experience in application of this procedure in everyday practice in regarding completeness and efficacy of the procedure, complication rate and incidence of recurrent adenomas.

METHODS

In the prospective study 51 colorectal adenomas were removed in 44 patients by EMR.

RESULTS

Single mucosectomy was done in 43 patients, while multiple (8) in one patient. Complete resection was obtained in all procedures. In 36 (68.62%) procedures "en block" resection was done, but in 15 (31.37%) procedures "piece meal" resection was performed. Synchronous colorectal tumors (benign or malignant) were detected in 20 (45.45%) patients. Moderate dysplasia was found in 30 (58.82%) adenomas, but high grade dysplasia in 9 (17.64%) of adenomas. Intramucosal CRC was detected in 11.77% of adenomas. A total of 37 (72.54%) advanced adenomas were removed. There were 3 (5.88%) of recurrent adenomas, 6-30 months after the EMR. Only one (2.2%) case of post procedure bleeding was observed.

CONCLUSION

EMR is a safe and efficious method for removal of flat, sessile adenomas, as well as early CRC. EMR is a routine endoscopic procedure in everyday practice of interventional endoscopist.

Clinical outcomes and factors related to resectability and curability of EMR for early colorectal cancer

BACKGROUND

EMR has emerged as an alternative therapeutic option for selected cases of early colorectal cancer (ECC). However, the factors associated with resectability and curability of EMR for ECC remain unknown.

OBJECTIVE

To investigate clinical outcomes and factors related to resectability and curability in ECC cases treated with EMR.

DESIGN

Retrospective study.

SETTING

Tertiary-care academic medical center.

PATIENTS

This study involved all patients in whom EMR was performed for ECC at Severance Hospital between March 1997 and August 2007. A total of 236 cases of ECC occurring in 231 patients (66.2% men) were enrolled.

INTERVENTION

EMR. Curative surgical resection and lymph node dissection were used in cases that were incompletely cured by EMR.

MAIN OUTCOME MEASUREMENTS

Resectability, curability, and recurrence.

RESULTS

Complete cure was achieved for 162 lesions (68.6%). Of the remaining 74 cases (31.4%), 69 (29.2%) were incompletely cured, and the other 5 (2.1%) had an undetermined resection status and ultimately required supplementary surgical resection for curative treatment. Location on the right side of the colon, piecemeal resection, and submucosal carcinoma were independently associated with incomplete resection, whereas depressed tumor type was independently related to incomplete cure. Among the ECC cases completely cured by EMR and followed for more than a year (n = 118), local recurrence was observed in one case (0.8%) during the median follow-up period of 39.4 months (range 12.4-123.1 months).

LIMITATIONS

Single-center, retrospective study.

CONCLUSION

Our data show that EMR is feasible and could be an effective option for treatment of ECC if the technique is applied with the appropriate indications.

Appointment waiting times and education level influence the quality of bowel preparation in adult patients undergoing colonoscopy

Background

Risk factors for poor bowel preparation are recognized to be independent of the type of bowel preparation method used. Patient and administrative factors influencing bowel preparation are known to vary in different healthcare systems.

Methods

A prospective, cross-sectional study of patients undergoing colonoscopy in an Asian tertiary centre was conducted to identify risk factors associated with poor bowel preparation, and to evaluate the impact of poor bowel preparation on technical performance and patient comfort.

Results

Data on 501 patients (mean age 60.1 ± 14.0 years old, 51.2% males, 60.9% with secondary education or higher) was available for analysis. Poor bowel preparation was present in 151 patients (30.1%). Lower education level (OR = 2.35, 95% CI = 1.54 - 3.60), colonoscopy appointment waiting time beyond 16 weeks (OR = 1.86, 95% CI = 1.04 - 3.37) and non-adherence to bowel preparation instructions (OR = 4.76, 95% CI = 3.00 - 7.55) were identified as independent risk factors for poor bowel preparation. Poor bowel preparation was associated with a lower cecal intubation rate (78.1% versus 98.3%, p < 0.001), prolonged total colonoscopy time (25.4 ± 12.6 minutes versus 16.7 ± 10.2 minutes, p < 0.001), and increased patient discomfort during colonoscopy (patient with moderate to severe abdominal discomfort 31.8% versus 3.2%, p < 0.001).

Conclusions

Education levels and appointment waiting times, in addition to non-adherence to bowel preparation instructions, increase the risk of poor bowel preparation in adult patients undergoing colonoscopy. The latter has a significant impact on colonoscopy performance and patient comfort.

Long-term functional results and quality of life after transanal endoscopic microsurgery

BACKGROUND

Of the few studies that have investigated quality-of-life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short-term follow-up data. This study assessed long-term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer.

METHODS

Preoperative and postoperative anorectal function was assessed in consecutive patients with benign rectal lesions or early rectal cancer, based on clinical scores and anorectal manometry.

RESULTS

Between January 2000 and July 2005, 93 patients undergoing TEM completed the 60-month study protocol. The mean Wexner continence score increased from baseline at 3 months, began to decline within 12 months, and had returned to the preoperative value at 60 months. Urgency was reported by 65·0, 30·0 and 5 per cent of patients at 3, 12 and 60 months respectively (P < 0·050). A significant improvement was noted in various clinical and QoL scores at 12 and 60 months. Postoperative manometry values at 3 months were significantly lower than at baseline (P < 0·050), but had returned to preoperative values at 12 months. Tumour size of 4 cm or above was the only factor that significantly (P = 0·008) affected the rectal sensitivity threshold, the urge to defaecate threshold and the maximum tolerated volume at 3 months after TEM.

CONCLUSION

TEM had no long-term effect on anorectal function or QoL. Lower anal resting pressure at early follow-up was not associated with defaecation problems in patients who were continent before surgery.

Comparing endoscopic submucosal dissection with transanal resection for non-invasive rectal tumor: a retrospective study

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is an alternative to transanal resection (TAR) in treating rectal adenomas, intramucosal cancers, and superficial submucosal cancers. The purpose of this study is to compare the clinical efficacy between ESD and TAR for non-invasive rectal tumors.

METHODS

Between January 1998 and December 2006, 85 patients with preoperative diagnosis of non-invasive rectal tumors were treated by ESD or TAR. En-bloc resection, local recurrence, complication, procedure time, and hospital stay were evaluated retrospectively using a prospectively-completed database.

RESULTS

Mean resection sizes were 40 mm and 39 mm in diameter for the ESD and TAR groups, respectively. En-bloc resections with a negative resection margin were achieved in 67% (35/52) of the ESD group, which was significantly higher than the 42% (14/33) in the TAR group. Sixty-three lesions were diagnosed as curative resection, histopathologically. There was no local recurrence in the ESD group, but five local recurrences developed in the TAR group. Two rectal perforations, one minor delayed bleeding, and one subcutaneous emphysema in the ESD group were successfully managed conservatively. There were one minor delayed bleeding and two anesthesia-related complications in the TAR group. The ESD group had a shorter hospital stay than the TAR group (4.9 days vs 7 days), but a longer procedure time (131 min vs 63 min).

CONCLUSION

ESD was more effective than TAR in treating non-invasive rectal tumors, with a lower recurrence rate and shorter hospital stay.

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in 2011, a Western perspective

Endoscopic mucosal resection (EMR) has become the standard of care for removal of large flat and sessile neoplastic lesions of the GI tract. Recently, endoscopic submucosal dissection (ESD) was introduced in Japan as an alternative technique, which allows en bloc resection of large lesions. The applications of EMR and ESD are expanding and many Western endoscopists are adopting these techniques. Paris classification and Kudo pit pattern classification allows prediction of the depth of invasion of early neoplastic lesions and thus, avoids resection of lesions invading the deep submucosa which have higher rates of lymphatic spread. ESD of early stomach cancer is the standard of care in Japan. Recent published reports from Western countries showed comparable results for ESD of early gastric cancers to those done in Japan. Recently, EMR combined with ablation has been used frequently in Western countries for treatment of high-grade dysplasia in early adenocarcinoma of the esophagus. Although ESD of early neoplastic lesions of the esophagus is technically difficult, few promising reports were published proving the feasibility of this technique in the West. ESD has been shown to achieve higher en bloc resection and lower rates of tumour recurrence in removal of lateral spreading colonic polyps. A hybrid technique of circumferential submucosal incision followed by en bloc EMR has been used for removal of large colonic lesions in some Western endoscopy centres. In Western countries, training for ESD is challenging given the lack of training in the relatively easier early gastric cancer lesions. Animal model training combined with observing experts in ESD could be an alternative for Western endoscopists. Inspite of obstacles, ESD applications are continuing to grow in Western countries.

Evidence and research perspectives for surgeons in the European Rectal Cancer Consensus Conference (EURECA-CC2)

PURPOSE

Although surgery remains the most important treatment of rectal cancer, the management of this disease has evolved to become more multidisciplinary to offer the best clinical outcome. The International Conference on Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) had the duty to identify the degree of consensus that could be achieved across a wide range of topics relating to the management of rectal cancer helping shape future programs, investigational protocols and guidelines for staging and treatment throughout Europe.

MATERIALS AND METHODS

Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round #2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by 85%.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.

Endoscopic mucosal resection of colorectal polyps in typical UK hospitals

AIM: To evaluate the outcomes of endoscopic mucosal resection (EMR) for colorectal polyps, with particular regard to procedural complications and recurrence rate, in typical United Kingdom (UK) hospitals that perform an average of about 25 colonic EMRs per year.

METHODS: A total of 239 colorectal polyps (≥ 10 mm) resected from 199 patients referred to Rochdale Infirmary, Salford Royal Hospital and Royal Oldham Hospital for EMR between January 2003 and January 2009 were studied.

RESULTS: The mean size of polyps resected was 19.6 ± 12.4 mm (range 10-80 mm). The overall major complication rate was 2.1%. Complications were less frequent with non-adenomas compared with the other groups (Pearson’s χ² test, P < 0.0001). Resections of larger-sized polyps were more likely to result in complications (unpaired t-test, P = 0.021). Recurrence was associated with histology, with carcinoma-in-situ more likely to recur compared with low-grade dysplasia [hazard ratio (HR) 186.7, 95% confidence interval (95% CI): 8.81-3953.02, P = 0.001]. Distal lesions were also more likely to recur compared with right-sided and transverse colon lesions (HR 5.93, 95% CI: 1.35-26.18, P = 0.019).

CONCLUSION: EMR for colorectal polyps can be performed safely and effectively in typical UK hospitals. Stricter follow-up is required for histologically advanced lesions due to increased recurrence risk.

Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan

Bleeding, perforation, and residual/local recurrence are the main complications associated with colonoscopic treatment of colorectal tumor. However, current status regarding the average incidence of these complications in Japan is not available. We conducted a questionnaire survey, prepared by the Colorectal Endoscopic Resection Standardization Implementation Working Group, Japanese Society for Cancer of the Colon and Rectum (JSCCR), to clarify the incidence of postoperative bleeding, perforation, and residual/local recurrence associated with colonoscopic treatment. The total incidence of postoperative bleeding was 1.2% and the incidence was 0.26% with hot biopsy, 1.3% with polypectomy, 1.4% with endoscopic mucosal resection (EMR), and 1.7% with endoscopic submucosal dissection (ESD). The total incidence of perforation was 0.74% (0.01% with the hot biopsy, 0.17% with polypectomy, 0.91% with EMR, and 3.3% with ESD). The total incidence of residual/local recurrence was 0.73% (0.007% with hot biopsy, 0.34% with polypectomy, 1.4% with EMR, and 2.3% with ESD). Colonoscopic examination was used as a surveillance method for detecting residual/local recurrence in all hospitals. The surveillance period differed among the hospitals; however, most of the hospitals reported a surveillance period of 3-6 months with mainly transabdominal ultrasonography and computed tomography in combination with the colonoscopic examination.

Polyp surveillance

Surveillance after colonic polypectomy is important to detect and remove missed synchronous polyps and cancers and new metachronous polyps or cancers. The authors review methods of surveillance and the risk of recurrent adenomas and provide surveillance recommendations.

Endoscopic resection of duodenal neoplasms: a single-center study

BACKGROUND

Premalignant duodenal lesions such as adenomas are rare. Surgical resection has been the standard approach to the treatment of these lesions. Endoscopic resection of superficial premalignant or malignant lesions of the gastrointestinal tract is used with increasing frequency. This study aimed to evaluate the safety and efficacy of endoscopic resection of duodenal neoplasms.

METHODS

Patients with nonampullary duodenal adenomas or duodenal adenocarcinomas without familial polyposis syndrome between August 2002 and February 2009 were retrospectively analyzed. Data including location and size, technique used for the endoscopic resection, complications, and follow-up evaluation of the lesions were reviewed.

RESULTS

The study enrolled 24 patients with duodenal neoplasms. Of these patients, 23 had duodenal adenomas and 1 had an adenocarcinoma confined to the mucosa. The mean age of the patients was 57 years (range, 40-82). In terms of location, 12 lesions (50%, 12/24) were found in the second portion of the duodenum, and 11 (45.8%, 11/24) were found in the first portion. Tubular adenomas were the most common type (17/24, 70.8%). There were four cases of the villotubular type and three of the villous type. Conventional endoscopic mucosal resection (EMR) was performed for 19 patients, EMR with ligation (EMR-L) for 3 patients, and snare polypectomy for 2 patients. Complete resection was achieved for 87.5% (21/24) of the patients, and the recurrence rate was 8.3% (2/24). All the complications were intraprocedural bleeding (n = 7), with no occurrence of perforation or infection. During a median follow-up period of 6 months (range, 3-36 months), recurrence of the duodenal neoplasm was observed in two cases. There was no procedure-related mortality.

CONCLUSIONS

Endoscopic resection of duodenal neoplasms was safe and effective treatment. During the short-term follow-up evaluation, EMR showed outcomes and complications comparable with prior procedures, including adenocarcinomas confined to the mucosa.

Large endoscopic mucosal resection for colorectal tumors exceeding 4 cm

AIM: To evaluate the feasibility and the outcome of endoscopic mucosal resection (EMR) for large colorectal tumors exceeding 4 cm (LCRT) undergoing piecemeal resection.

METHODS: From January 2005 to April 2008, 146 digestive tumors larger than 2 cm were removed with the EMR technique in our department. Of these, 34 tumors were larger than 4 cm and piecemeal resection was carried out on 26 colorectal tumors. The mean age of the patients was 71 years. The mean follow-up duration was 12 mo.

RESULTS: LCRTs were located in the rectum, left colon, transverse colon and right colon in 58%, 15%, 4% and 23% of cases, respectively. All were sessile tumors larger than 4 cm with a mean size of 4.9 cm (4-10 cm). According to the Paris classification, 34% of the tumors were type Is, 58% type IIa, 4% type IIb and 4% type IIc. Pathological examination showed tubulous adenoma in 31%, tubulo-villous adenoma in 27%, villous adenoma in 42%, high-grade dysplasia in 38%, in situ carcinoma in 19% of the cases and mucosal carcinoma (m2) in 8% of the cases. The two cases (7.7%) of procedural bleeding that occurred were managed endoscopically and one small perforation was treated with clips. During follow-up, recurrence of the tumor occurred in three patients (12%), three of whom received endoscopic treatment.

CONCLUSION: EMR for tumors larger than 4 cm is a safe and effective procedure that could compete with endoscopic submucosal dissection, despite providing incomplete histological assessment.

Clinicopathologic features and endoscopic mucosal resection of laterally spreading tumors: experience from China

BACKGROUND

Laterally spreading tumors (LSTs) are being increasingly reported nowadays in Japan and the western countries with the application of magnification chromoendoscopy. The aim of this study was to analyze the clinicopathologic features of LSTs and to assess the outcome and safety of endoscopic mucosal resection (EMR) in China.

PATIENTS AND METHODS

One hundred nine patients with LSTs who underwent magnification chromoendoscopy were studied retrospectively. Clinicopathological features of 111 LSTs were analyzed. The efficacy and safety of EMR was assessed in 79 LSTs based on the outcome of follow-up colonoscopy and resection-related complications.

RESULTS

A total of 111 LSTs were diagnosed in 109 patients, including 89 (80%) laterally spreading tumor-granular (LST-G) type and 22 (20%) laterally spreading tumor-non-granular (LST-NG) type. There was significant difference in the dominant pit pattern between LST-G type and LST-NG type (p < 0.001). Type IV pit pattern (62%) was the main crypt pattern in LST-G type; whereas, type IIIL (50%) and type V pit pattern (36%) were predominant crypt patterns in LST-NG type. EMR was performed for 103 lesions. Six of the nine lesions with type V(I) pit pattern were completely resected by EMR. Eleven (14%) local recurrent lesions were detected in 79 follow-up lesions and were treated successfully during the follow-up.

CONCLUSIONS

The type of dominant pit pattern was different between LST-G type and LST-NG type. Many LSTs with a type V(I) pit pattern can be completely resected by EMR. EMR technique is a safe and efficacious treatment method for LST.

Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2)

BACKGROUND AND PURPOSE

During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO).

METHODS

Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", and "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.

Lymphatic vessel invasion detected by monoclonal antibody D2-40 as a predictor of lymph node metastasis in T1 colorectal cancer

OBJECTIVE

When selecting patients who are at high risk for lymph node metastasis, the detection of lymphatic vessel invasion (LVI) is important. We investigated LVI detected by D2-40 staining as a predictor of lymph node metastasis in T1 colorectal cancer.

MATERIALS AND METHODS

Clinicopathological factors including LVI were investigated in 136 patients who underwent colectomy with lymph node dissection for T1 colorectal cancer. We used immunostaining with monoclonal antibody D2-40 to detect LVI.

RESULTS

Lymph node metastases were found in 18 patients (13.2%), and LVI were detected in 45 (33%); lymph node metastasis was more frequently observed in LVI-positive groups (13/45 vs 5/91, p < 0.001). Both univariate and multivariate analyses revealed that LVI detected by D2-40 and a poorly differentiated histology at the invasion front were independent risk factors of lymph node metastasis.

CONCLUSION

LVI detected by D2-40 is important for the prediction of lymph node metastasis.

Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes

Open access endoscopy and screening programs enable detection and removal of an increased number of colon polyps in the early stages of neoplastic transformation. Unfortunately, polyps larger than 3 cm, involving more than one-third of circumference or two haustral folds, or with a flat/depressed morphology are more challenging to remove with standard polypectomy techniques. Endoscopic mucosal resection potentiates the removal, in a minimally invasive way, of certain colonic lesions that would otherwise require surgical or ablative treatment. Because the plane of resection during endoscopic mucosal resection is typically the middle to deep submucosal layer, compared with standard polypectomy, which normally provides resection at a mucosal level, endoscopic mucosal resection offers the advantage of providing en bloc resection specimens for histopathologic analysis. Indications to perform endoscopic mucosal resection are adenoma and small, well-differentiated carcinoma, confined to the mucosa or with minimal invasion to submucosa, and without any invasion to lymphatic channels or vessels. The most frequently reported major complications, such as perforation (0-5%) and bleeding (0.5-6%), may be controlled by endoscopic methods and rarely require surgical treatment. Follow-up postendoscopic mucosal resection is essential because of the risk of neoplastic recurrence.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical technique that was developed more than two decades ago to manage distal colorectal neoplasias. The aim of the current study was to present a prospective review of 7 years of experience in using this equipment. All patients undergoing TEM between 1999 and 2007 were prospectively evaluated. Patients underwent regular endoscopic follow up. Cumulative incidence probability analysis was used to calculate rates of recurrence. The study involved 232 patients, median age 68 years (interquartile range (IQR), 37-90). The median neoplasia area was 12 cm(2) (IQR, 6-25 cm(2)) and the median height above the anal verge was 9 cm (IQR, 3-17 cm). Histology indicated 128 adenomas, 52 carcinomas in situ, and 52 adenocarcinomas. The median postoperative stay was 1 day (IQR, 1-3 days). There was one (0.5%) unplanned return to theatre and no postoperative deaths. Sixteen patients (6.9%) underwent more radical surgical procedures following the identification of carcinoma in the resected specimen. During a median follow up of 4.2 years (IQR, 2.6-6.2 years), the 5-year cumulative incidence for local recurrence for benign pathology was 3.1% (95% confidence interval (CI): 1.2-6.7%, n = 180) and for cancers managed primarily by TEM excision it was 8.5% (95%CI: 1.4-23.9%, n = 36). TEM is an excellent treatment modality for benign rectal neoplasias of any size, and in any location. TEM is an oncologically inferior treatment for rectal cancer, however, when compared to more radical treatments. Its principal advantage in this setting is that it is associated with relatively minimal morbidity and mortality.

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background

Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications.

The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas.

Methods/design

Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment.

Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures.

Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group.

Discussion

The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas.

Trial registration number

(trialregister.nl) NTR1422

Indications for subsequent surgery after endoscopic resection of submucosally invasive colorectal carcinomas: a prospective cohort study

PURPOSE

This study explored predictive factors that affected oncologic outcomes after surgical resection or follow-up without surgery in patients with submucosally invasive colorectal carcinomas after endoscopic resection.

METHODS

Oncologic outcomes in terms of lymph node metastasis or tumor recurrence were assessed according to resection margin, histology, and depth of invasion.

RESULTS

Eighty-seven patients with submucosally invasive colorectal carcinomas after endoscopic resection were followed prospectively. Fifty-seven (65.5 percent) patients had risk factors of deep submucosal invasion and/or unfavorable histology. Among them, 30 underwent radical resection, and 6 patients had lymph node metastases. Twenty patients with risk factors were closely followed up and 3 recurrent carcinomas were detected. Ultimately, 9 of 57 high-risk patients (15.8 percent) exhibited lymph node metastasis or tumor recurrence. Among 30 patients without risk factors, none had lymph node metastasis or recurrent carcinoma. Univariate analysis showed that tumor budding (P = 0.003) and venous invasion (P = 0.021) were factors for lymph node metastasis. In multivariate analysis, only tumor budding was an independent predictor of lymph node metastasis (P = 0.026).

CONCLUSIONS

Approximately 16 percent of patients with submucosally invasive colorectal carcinoma and risk factors benefited from subsequent surgery. Tumor budding was the most significant factor for lymph node metastasis. Observation would be appropriate for patients without risk factors after endoscopic resection.

Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis

OBJECTIVE

A prospective technical feasibility study of cap assisted ESD for 'curative intent' in patients with residual or local neoplastic recurrence following EMR. Primary end points were second stage R0 resection rate, safety and recurrence.

METHOD

Salvage ESD was performed using the Olympus GIF-XQ240 gastroscope and KD-630L insulation tipped knife. Thirty-day mortality, re-admission rates, complications and histological resection status were collected prospectively up to 9 months following index resection.

RESULTS

Thirty patients met eligibility criteria. Index R0 resection was achieved in 25/30 (83%) lesions. One patient underwent surgical excision with a second receiving a curative second stage dissection. Ninety-six per cent (29/30) patients were discharged within 24 h of the procedure with a 0% 30-day mortality and re-admission rate. Bleeding occurred in 5/30 (16%) treated successfully with endoluminal haemostasis. There were no perforations. Overall 'cure' rates at short-term follow-up [median 6/12 (range; 3-18)] was 96%.

CONCLUSION

This novel application of ESD for first line 'salvage' therapy in treating residual or locally recurrent neoplastic disease may be a safe, minimally invasive and cost effective alternative to direct surgical resection in a select patient cohort.

Endoluminal resection for sessile neoplasia in the GI tract is associated with a low recurrence rate and a high 5-year survival rate

BACKGROUND

Endoluminal resection (ELR) is an alternative to surgery for the removal of superficial neoplastic lesions of the GI tract. We previously reported a complete resection (CR) rate of 89% when using ELR techniques. However, the long-term efficacy of ELR for the eradication of sessile lesions, as well as patient survival after ELR, is not known.

OBJECTIVES

To assess the long-term recurrence rate of GI lesions that were completely resected by ELR and to determine the long-term (5-year) survival rate of patients who had ELR for GI lesions that contained high-grade dysplasia (HGD) or adenocarcinoma (AdCa).

DESIGN

From a larger cohort of 92 consecutive patients who had undergone ELR of sessile lesions from 1997 to 2000, long-term follow-up was obtained. Patient survival rates were considered in terms of disease-specific mortality.

RESULTS

Endoscopic follow-up was possible in 44 patients (48%) and 46 lesions (46%). At the time of the initial ELR, the median age was 68.5 years. The median duration of follow-up was 3.8 years after ELR (range 7 months to 8.1 years). Resected lesions were located in the esophagus (25%), stomach (11%), duodenum (25%), colon (27%), and rectum (11%). Post-ELR histopathology consisted of adenomas (46%), HGD (16%), AdCa (11%), lymphoma (2%), leiomyoma (2%), carcinoid (2%), lesions indeterminate for dysplasia (2%), and nondysplastic lesions (18%). CR was achieved in 42 patients and 44 lesions (96%) after initial ELR procedures (range 1-3). Thirty-seven of 39 neoplastic lesions (95%) in this cohort achieved initial CR. Two lesions (found in 2 patients) that did not achieve initial CR were excluded from analysis. Four of 37 neoplastic lesions (10.8%) that underwent successful ELR had local recurrence of neoplasia (median time to recurrence was 1.9 years). Two of the 4 neoplastic recurrences were successfully eradicated by subsequent endoscopic techniques (95% overall eradication rate). Long-term endoscopic follow-up was possible in 12 of 20 patients (60%) with HGD or AdCa who achieved initial CR. These 12 patients had HGD (n = 7) or AdCa (n = 5) and were observed for an average of 4.9 years (range 1.4-7.9 years) after an ELR. Two of these patients died during follow-up, but only 1 death (8%) was lesion related. When comparing post-ELR pathology, HGD and AdCa trended toward an increased risk of recurrence compared with other neoplastic lesions (hazard ratio 4.75 [95% CI, 0.49-46.35], P = .18).

LIMITATIONS

A retrospective study with 52% of patients lost to long-term endoscopic follow-up, which limited the sample size and the number of events.

CONCLUSIONS

ELR effectively eradicates sessile neoplastic lesions from the GI tract, with a low recurrence rate (10.8%) at long-term follow-up. Post-ELR surveillance is important, because local recurrences may be amenable to endoscopic eradication. HGD and cancers may carry an increased risk for a local recurrence, with a 5-year disease-specific survival of 92%. This study suggests that ELR is associated with a low recurrence rate for neoplastic lesions and appreciable long-term survival in patients with highly dysplastic lesions. Additional, long-term follow-up studies are necessary to investigate the role of ELR in the treatment of highly dysplastic lesions of the GI tract.

Endoscopic mucosal resection of colonic lesions: current applications and future prospects

The introduction of submucosal fluid injection has remarkably extended the range of endoscopically resectable polyps. The limiting factor for endoscopic resection is not polyp size, but polyp depth. Endoscopic ultrasound is a useful adjunctive diagnostic tool to assess the depth of invasion. The success of are section ultimately depends on pathologic confirmation of a benign nature of this lesion or of a cancer limited to the mucosa. Selected well-differentiated cancers without lymphovascular invasion of the superficial submucosa can be successfully resected endoscopically.