Colorectal cancer is one of the most frequent malignancies in the world and is the third leading cause of cancer-related death in Sweden. Neoplastic polyps (adenoma) are considered to be precursors of cancers in the colon and rectum. Stalked polyps can easily be removed by use of snare polypectomy. Sessile and flat adenomas can be eliminated efficiently using endoscopic mucosal resection (EMR) [
From January 2012 to March 2013, 29 patients with early colorectal neoplasms underwent ESD at the Department of Endoscopy at Skåne University Hospital in Malmö, Sweden. Patients were considered eligible for colorectal ESD if they had a colorectal lesion larger than 20 mm in diameter or a local recurrence after EMR with extensive fibrosis. In principal, only cases with low- or high-grade dysplasia were enrolled for colonic ESD. Tumors showing evidence of regions of hardness, irregular nodules, ulceration, or submucosal tumor-like marginal elevation suggestive of submucosal invasion more than 1000
Colonic cleansing was based on intake of four liters of polyethylene glycol prior to the ESD procedure. All patients underwent conscious sedation by use of intravenous administration of midazolam hydrochloride (Panpharma, Fougères, France) and analgesia with ketobemidone chloride (Pfizer Inc. New York, USA). Midazolam administration was reiterated if necessary. An intravenous injection of 20 mg of scopolamine butylbromide (Buscopan, Boehringer Ingelheim, Ingelheim, Germany) or one mg of glucagon (Novo Nordisk A/S Bagsvaerd, Denmark) was given to reduce intestinal peristalsis. Carbon dioxide insufflation was used during colorectal ESD in order to minimize patient discomfort. A colorectal surgeon with extensive experience in invasive endoscopy (H.T.) performed all procedures. The main outcomes were en bloc and curative resection rate, procedural time, and complications. ESD procedures in the descending and sigmoid colon as well as the rectum were conducted with a gastroscope (GIF-H180J, Olympus, Hamburg, Germany) and in the cecum, ascending and transverse colon by use of a colonoscope (CF-H180AI, Olympus). Topical administration of 0.4% indigo carmine and narrowband imaging was used to delineate the lesions (Figure
Standard procedure for colorectal ESD. (a) A large (3 × 4 cm) laterally spreading tumor-nongranular type in the transverse colon is delineated by use of topical application of indigo carmine. One can also see the frontal part of the disposable hood. (b) The lesion is elevated by submucosal injection of hyaluronic acid solution, and the anal part of the tumor has been incised by use of a Flush-knife. (c) The Flush-knife is used to dissect the submucosa and separate it from muscularis propria. (d) When approximately half of the lesion has been separated from the muscularis propria, the mucosal incision is completed around the lesion. (e) The lesion has been resected en bloc, and the remaining ulcer is examined for potential perforations and exposed blood vessels to coagulate. (f) The resected specimen is stretched and nailed to facilitate histological examination.
Resected specimens were immersed in 10% formalin and fixed specimens were sectioned serially at 2 mm intervals and subjected to histological examination. Vienna classification of gastrointestinal epithelial neoplasia was used to classify the colorectal neoplasms [
Perforation during an ESD procedure was classified into immediate and delayed perforations, during and after completion of the procedure, respectively. Perforations were defined as small holes with visible omentum or other tissue outside the muscle layer, such as transparent serosa, visualized endoscopically, and free air in the abdomen demonstrated on image studies. Procedure-related bleeding was defined as clinical evidence of hemorrhage with melena or hematochezia requiring a special hemostatic method after the ESD procedure. If a bleeding during the procedure caused abortion of the ESD intervention, it was considered to be a complication. Follow-up colonoscopy was planned 3–6 months after ESD. A biopsy was performed for histological assessment of any suspicious abnormality.
Data are given as median and range. The ESD procedure was performed in accordance with the ethical principles of the Declaration of Helsinki. All patients received a detailed explanation of the procedure, including risks of bleeding, perforation, and the possibility of additional surgery due of complications or histological diagnosis of resected specimens.
Twenty-nine patients were included in the study of which 14 were males and 15 females (Figure
Patient and tumor characteristics.
Total | |
---|---|
Total number of patients | 29 |
Age (years) | 74 (46–85) |
Gender, |
|
Male | 14 (48%) |
Female | 15 (52%) |
Tumor size (mm) |
28 (11–89) |
Tumor location, |
|
Cecum | 4 (14%) |
Transverse colon | 2 (7%) |
Sigmoid colon | 6 (21%) |
Rectum | 17 (59%) |
Macroscopic type, |
|
Sessile | 10 (34%) |
LST-G | 12 (41%) |
LST-NG | 7 (24%) |
Histology, |
|
Low-grade adenoma | 19 (66%) |
High-grade adenoma | 5 (17%) |
Adenocarcinoma, sm1 | 3 (10%) |
Adenocarcinoma, >sm1 | 2 (7%) |
LGT-G: laterally spreading tumor-granular type; LST-NG: laterally spreading tumor-nongranular type; sm1: submucosal invasion <1000
Outcome of colorectal ESD. ESD: endoscopic submucosal dissection; R0 : R0 resection; R1 : R1 resection; TEM: transanal endoscopic microsurgery.
En bloc resection rate was achieved in 21 cases (72%), while R0 resection rate was achieved in 20 patients (69%) (Figure
The advantage of ESD compared to EMR is that large colorectal tumors can be removed en bloc, which facilitates the pathological evaluation of the specimen and reduces the risk of local recurrence compared to EMR. The disadvantage with ESD is that this method is technically challenging to learn and that the risk of perforation is higher than that of EMR. Although most ESD-associated perforations are treated conservatively and rarely require surgical intervention, some perforations are indeed fatal. These factors have restricted the dissemination of colorectal ESD in western countries. This present study shows that implementation of colorectal ESD is possible in Sweden and represents the first data on colorectal ESD performed at a specialized center in Scandinavia.
Piecemeal resection is associated with increased risk of incomplete resection and local recurrence [
Intestinal perforation is the most feared complication in colorectal ESD. The rate of perforations varies between 1 and 10% in experienced centers in Japan [
One challenge with ESD is that the procedure time is significantly longer than that of EMR. Herein, we observed that the median ESD procedure time was 142 min, which is not only longer than that of EMR but also significantly longer than procedural times (61–116 min) reported from experienced centers in Japan [
One limitation of this study is that we did not perform a randomized trial comparing ESD and EMR. Such prospective randomized trials could be helpful to evaluate the role of ESD in the management of early and large colorectal neoplasms in Sweden. Our experience is that besides training in animal models, one should obtain direct experience from experts in Japan before attempting ESD in the gastrointestinal tract. It is also extremely helpful if experts from Japan can directly supervise when starting ESD programs outside Japan. In Japan, endoscopists start to do ESD in the stomach since the incidence of early gastric lesions is high there. In western countries where the frequency of early gastric lesion is low, one must rather start with ESD in the rectum. Once proficiency is obtained in doing rectal ESD, one can move forward and attempt ESD in the colon and esophagus. This model for learning ESD in Sweden is in line with recent European recommendations [
We conclude that ESD is an effective method for en bloc resection of large adenomas and early cancers in the colon and rectum. Moreover, our results demonstrate that ESD is a safe method for managing large colorectal lesions when performed by an experienced interventional endoscopist combined with careful patient selection. Further studies are needed to compare ESD and EMR in terms of efficacy and cost benefit in randomized trials. Nonetheless, the present study suggests that implementation of colorectal ESD is feasible in Sweden.
The authors have no potential conflict of interests (financial, professional, or personal).
This study was supported by the Swedish Medical Research Council (2012-3685). Malmö University Hospital and Lund University.