Advertisement

Surgical Endoscopy

, Volume 24, Issue 2, pp 343–352 | Cite as

Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection

  • Yutaka Saito
  • Masakatsu Fukuzawa
  • Takahisa Matsuda
  • Shusei Fukunaga
  • Taku Sakamoto
  • Toshio Uraoka
  • Takeshi Nakajima
  • Hisatomo Ikehara
  • Kuang-I Fu
  • Takao Itoi
  • Takahiro Fujii
Article

Abstract

Background and Aims

Endoscopic submucosal dissection (ESD) has recently been applied to the treatment of superficial colorectal cancer. Clinical outcomes compared with conventional endoscopic mucosal resection (EMR) have not been determined so our aim was to compare the effectiveness of ESD with conventional EMR for colorectal tumors ≥20 mm.

Methods

This was a retrospective case-controlled study performed at the National Cancer Center Hospital in Tokyo, Japan involving 373 colorectal tumors ≥20 mm determined histologically to be curative resections. Data acquisition was from a prospectively completed database. We evaluated histology, tumor size, procedure time, en bloc resection rate, recurrence rate, and associated complications for both the ESD and EMR groups.

Results

A total of 145 colorectal tumors were treated by ESD and another 228 were treated by EMR. ESD was associated with a longer procedure time (108 ± 71 min/29 ± 25 min; p < 0.0001), higher en bloc resection rate (84%/33%; p < 0.0001) and larger resected specimens (37 ± 14 mm/28 ± 8 mm; p = 0.0006), but involved a similar percentage of cancers (69%/66%; p = NS). There were three (2%) recurrences in the ESD group and 33 (14%) in the EMR group requiring additional EMR (p < 0.0001). The perforation rate was 6.2% (9) in the ESD group and 1.3% (3) in the EMR group (p = NS) with delayed bleeding occurring in 1.4% (2) and 3.1% (7) of the procedures (p = NS), respectively, as all complications were effectively treated endoscopically.

Conclusions

Despite its longer procedure time and higher perforation rate, ESD resulted in higher en bloc resection and curative rates compared with EMR and all ESD perforations were successfully managed by conservative endoscopic treatment.

Keywords

Endoscopic submucosal dissection (ESD) Endoscopic mucosal resection (EMR) Recurrence Colon Colorectal Short-term clinical outcome 

Abbreviations

B-knife

Bipolar needle knife

CO2

Carbon dioxide

EMR

Endoscopic mucosal resection

EPMR

Endoscopic piecemeal mucosal resection

ESD

Endoscopic submucosal dissection

IT knife

Insulation-tipped knife

LN

Lymph node

sm

Submucosal

LST

Laterally spreading tumor

LST-G

Laterally spreading tumor granular type

LST-NG

Laterally spreading tumor nongranular type

NS

Not significant

SD

Standard deviation

sm1

Minute submucosal cancer

sm2

Submucosal deep cancer

Notes

Acknowledgement

The authors wish to thank Christopher Dix for helping to edit this manuscript.

References

  1. 1.
    Ahmad NA, Kochman ML, Long WB, Furth EE, Ginsberg GG (2002) Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases. Gastrointest Endosc 55:390–396CrossRefPubMedGoogle Scholar
  2. 2.
    Yokota T, Sugihara K, Yoshida S (1994) Endoscopic mucosal resection for colorectal neoplastic lesions. Dis Colon Rectum 37:1108–1111CrossRefPubMedGoogle Scholar
  3. 3.
    Soetikno RM, Gotoda T, Nakanishi Y, Soehendra N (2003) Endoscopic mucosal resection. Gastrointest Endosc 57:567–579CrossRefPubMedGoogle Scholar
  4. 4.
    Tada M, Murakami A, Karita M, Yanai H, Okita K (1993) Endoscopic resection of early gastric cancer. Endoscopy 25:445–450CrossRefPubMedGoogle Scholar
  5. 5.
    Deyle P, Largiader F, Jenny S, Fumagalli I (1973) A method for endoscopic electrosection of sessile colonic polyp. Endoscopy 5:38–40CrossRefGoogle Scholar
  6. 6.
    Kudo S (1993) Endoscopic mucosal resection of flat and depressed type of early colorectal cancer. Endoscopy 25:455–461CrossRefPubMedGoogle Scholar
  7. 7.
    Saito Y, Fujii T, Kondo H, Mukai H, Yokota T, Kozu T et al (2001) Endoscopic treatment for laterally spreading tumors in the colon. Endoscopy 33:682–686CrossRefPubMedGoogle Scholar
  8. 8.
    Tanaka S, Haruma K, Oka S, Takahashi R, Kunihiro M, Kitadai Y et al (2001) Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. Gastrointest Endosc 54:62–66CrossRefPubMedGoogle Scholar
  9. 9.
    Kudo S, Kashida H, Tamura T, Kogure E, Imai Y, Yamano H et al (2000) Colonoscopic diagnosis and management of nonpolypoid early colorectal cancer. World J Surg 24:1081–1090CrossRefPubMedGoogle Scholar
  10. 10.
    Uraoka T, Saito Y, Matsuda T, Ikehara H, Gotoda T, Saito D et al (2006) Endoscopic indications for endoscopic mucosal resection of laterally spreading tumors in the colorectum. Gut 55:1592–1597CrossRefPubMedGoogle Scholar
  11. 11.
    Min BH, Lee JH, Kim JJ, Shim SG, Chang DK, Kim YH et al (2009) Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: Comparison with endoscopic mucosal resection after circumferential precutting (EMR-P). Dig Liver Dis 41:201–209CrossRefPubMedGoogle Scholar
  12. 12.
    Walsh RM, Ackroyd FW, Shellito PC (1992) Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc 38:303–309CrossRefPubMedGoogle Scholar
  13. 13.
    Hosokawa K, Yoshida S (1998) Recent advances in endoscopic mucosal resection for early gastric cancer. Jpn J Cancer Chemother 25:476–483 (in Japanese with English abstract)Google Scholar
  14. 14.
    Ohkuwa M, Hosokawa N, Boku N, Ohtsu H, Tajiri S, Yoshida S (2001) New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife. Endoscopy 33:221–226CrossRefPubMedGoogle Scholar
  15. 15.
    Ono H, Kondo H, Gotoda T, Shirao K, Yamaguchi H, Saito D et al (2001) Endoscopic mucosal resection for treatment of early gastric cancer. Gut 48:225–229CrossRefPubMedGoogle Scholar
  16. 16.
    Kondo H, Gotoda T, Ono H, Oda I, Kozu T, Fujishiro M et al (2004) Percutaneous traction-assisted EMR by using an insulation-tipped electrosurgical knife for early stage gastric cancer. Gastrointest Endosc 59:284–288CrossRefPubMedGoogle Scholar
  17. 17.
    Kobayashi T, Gotohda T, Tamakawa K, Ueda H, Kakizoe T (2004) Magnetic anchor for more effective endoscopic mucosal resection. Jpn J Clin Oncol 34:118–123CrossRefPubMedGoogle Scholar
  18. 18.
    Gotoda T, Kondo H, Ono H, Saito Y, Yamaguchi H, Saito D et al (1999) A new endoscopic resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc 50:560–563CrossRefPubMedGoogle Scholar
  19. 19.
    Kodashima S, Fujishiro M, Yahagi N, Kakushima N, Omata M (2006) Endoscopic submucosal dissection using flexknife. J Clin Gastroenterol 40:378–384CrossRefPubMedGoogle Scholar
  20. 20.
    Sano Y, Fu KI, Saito Y, Doi T, Hanafusa M, Fujii S et al (2006) A newly developed bipolar-current needle-knife for endoscopic submucosal dissection of large colorectal tumors. Endoscopy 38(Suppl 5):E95CrossRefPubMedGoogle Scholar
  21. 21.
    Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y et al (2007) A pilot study to assess safety and efficacy of carbon dioxide insufflation during colorectal endoscopic submucosal dissection under conscious sedation. Gastrointest Endosc 65:537–542CrossRefPubMedGoogle Scholar
  22. 22.
    Yamamoto H, Kawata H, Sunada K, Satoh K, Kaneko Y, Ido K et al (2002) Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate. Gastrointest Endosc 56:507–512CrossRefPubMedGoogle Scholar
  23. 23.
    Yamamoto H, Kawata H, Sunada K, Sasaki A, Nakazawa K, Miyata T et al (2003) Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 35:690–694CrossRefPubMedGoogle Scholar
  24. 24.
    Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y et al (2007) Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 66(5):966–973CrossRefPubMedGoogle Scholar
  25. 25.
    Antillon MR, Bartalos CR, Miller ML, Diaz-Arias AA, Ibdah JA, Marshall JB (2008) En bloc endoscopic submucosal dissection of a 14-cm laterally spreading adenoma of the rectum with involvement to the anal canal: expanding the frontiers of endoscopic surgery (with video). Gastrointest Endosc 67:332–337CrossRefPubMedGoogle Scholar
  26. 26.
    Uraoka T, Kato J, Ishikawa S, Harada K, Kuriyama M, Takemoto K et al (2007) Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos). Gastrointest Endosc 66:836–839CrossRefPubMedGoogle Scholar
  27. 27.
    Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S et al (2007) Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol 5(6):674–677CrossRefGoogle Scholar
  28. 28.
    Tamegai Y, Saito Y, Masaki N, Hinohara C, Oshima T, Kogure E et al (2007) Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 39:418–422CrossRefPubMedGoogle Scholar
  29. 29.
    Fujii T, Hasegawa RT, Saitoh Y, Fleischer D, Saito Y, Sano Y et al (2001) Chromoscopy during colonoscopy. Endoscopy 33:1036–1041PubMedGoogle Scholar
  30. 30.
    Saito Y, Emura F, Matsuda T, Saito D, Fujii T (2004) Invasive pattern is an indication for surgical treatment (letter to the editor). Gut online (serial online), Mar. Available at http://gut.bmjjournals.com/cgi/eletters/53/2/284
  31. 31.
    Matsuda T, Fujii T, Saito Y, Nakajima T, Uraoka T, Kobayashi N et al (2008) Efficacy of the invasive/non-invasive pattern by magnifying estimate the depth of invasion of early colorectal neoplasms. Am J Gastroenterol 103(11):2700–2706CrossRefPubMedGoogle Scholar
  32. 32.
    Uraoka T, Fujii T, Saito Y, Sumiyoshi T, Emura F, Bhandari P et al (2005) Effectiveness of glycerol as a submucosal injection for EMR. Gastrointest Endosc 61:736–740CrossRefPubMedGoogle Scholar
  33. 33.
    Yamamoto H, Sekine Y, Higashizawa T, Kihira K, Kaneko Y, Hosoya Y et al (2001) Successful en-bloc resection of a large superficial gastric cancer by using sodium hyaluronate and electrocautery incision forceps. Gastrointest Endosc 54:629–632CrossRefPubMedGoogle Scholar
  34. 34.
    Kitajima K, Fujimori T, Fujii S, Takeda J, Ohkura Y, Kawamata H et al (2004) Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol 39:534–543CrossRefPubMedGoogle Scholar
  35. 35.
    Japanese Research Society for Cancer of the Colon and Rectum (1998) General rules for clinical and pathological studies on cancer of the colon, rectum and anus: histopathological classification, 6th edn. Kanehara Syuppan, Tokyo, pp 60–90Google Scholar
  36. 36.
    Schlemper RJ, Riddell RH, Kato Y, Borchard F, Cooper HS, Dawsey SM et al (2000) The Vienna classification of gastrointestinal epithelial neoplasia. Gut 47:251–255CrossRefPubMedGoogle Scholar
  37. 37.
    Hotta K, Fujii T, Saito Y, Matsuda T (2009) Local recurrence after endoscopic resection of colorectal tumors. Int J Colorectal Dis 24(2):225–230CrossRefPubMedGoogle Scholar
  38. 38.
    Hurlstone DP, Cross SS, Brown S, Sanders DS, Lobo AJ (2004) A prospective evaluation of high-magnification chromoscopic colonoscopy in predicting completeness of EMR. Gastrointest Endosc 59:642–650CrossRefPubMedGoogle Scholar
  39. 39.
    Kato S, Fujii T, Koba I, Sano Y, Fu KI, Parra-Blanco A et al (2001) Assessment of colorectal lesions using magnifying colonoscopy and mucosal dye spraying: can significant lesions be distinguished? Endoscopy 33:306–310CrossRefPubMedGoogle Scholar
  40. 40.
    Fu KI, Sano Y, Kato S, Fujii T, Nagashima F, Yoshino T et al (2004) Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study. Endoscopy 36:1089–1093CrossRefPubMedGoogle Scholar
  41. 41.
    Emura F, Saito Y, Taniguchi M, Fujii T, Tagawa K, Yamakado M (2007) Further validation of magnifying chromocolonoscopy to differentiate colorectal neoplastic polyps in a health screening center. J Gastroenterol Hepatol 22:1722–1727CrossRefPubMedGoogle Scholar
  42. 42.
    Taku K, Sano Y, Fu KI, Saito Y, Matsuda T, Uraoka T et al (2007) Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol 22(9):1409–1414CrossRefPubMedGoogle Scholar
  43. 43.
    Kobayashi N, Saito Y, Uraoka T, Matsuda T, Suzuki H, Fujii T (in press) Treatment strategy for laterally spreading tumors in Japan: before and after the introduction of colorectal endoscopic submucosal dissection. J Gastroenterol HepatolGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Yutaka Saito
    • 1
  • Masakatsu Fukuzawa
    • 1
    • 2
  • Takahisa Matsuda
    • 1
  • Shusei Fukunaga
    • 1
  • Taku Sakamoto
    • 1
  • Toshio Uraoka
    • 1
    • 3
  • Takeshi Nakajima
    • 1
  • Hisatomo Ikehara
    • 1
    • 4
  • Kuang-I Fu
    • 1
    • 5
  • Takao Itoi
    • 1
    • 2
  • Takahiro Fujii
    • 1
    • 6
  1. 1.Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
  2. 2.Department of Gastroenterology and HepatologyTokyo Medical UniversityTokyoJapan
  3. 3.Department of EndoscopyOkayama University HospitalOkayamaJapan
  4. 4.Endoscopy and Gastrointestinal OncologyShizuoka Cancer CenterShizuokaJapan
  5. 5.Department of GastroenterologyJuntendou University Nerima HospitalTokyoJapan
  6. 6.Takahiro Fujii ClinicTokyoJapan

Personalised recommendations