Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience
Endoscopic submucosal dissection (ESD) allows for en bloc resection of superficial gastrointestinal neoplasms; however, US experience has been limited. We aimed to evaluate our clinical outcomes in colorectal ESD.
This prospective study included consecutive patients undergoing colorectal ESD at a major US center. Demographics, lesion and technical characteristics, outcomes, adverse events, and pathological diagnoses were recorded. Factors affecting resection outcomes and procedure time were evaluated.
77 patients who underwent colorectal ESD were analyzed. Mean colorectal lesion diameter was 49.4 mm. Mean procedure time was 104.7 min, and 97.4% of patients were discharged home on the same day. En bloc, complete, and curative resection was achieved in 97.4%, 97.4%, and 93.5% of colorectal ESD cases. Microperforation and delayed bleeding rates were 1.3% and 3.9%. On univariable analysis, the presence of tattoo adversely affected en bloc resection (p = 0.002), complete resection (p = 0.002), and curative resection (p = 0.008). Prior EMR attempts adversely affected en bloc resection (p = 0.028), complete resection (p = 0.028), and procedure time (p = 0.008). On multivariable analysis, the presence of tattoo predicted failure to achieve curative resection (OR 0.13; 95% CI 0.02–0.98; p = 0.048). Lesion size > 50 mm (OR 3.89; 95% CI 1.13–13.41; p = 0.031), presence of tattoo (OR 9.38; 95% CI 1.05–83.83; p = 0.045), and prior EMR attempts (OR 7.13; 95% CI 1.76–28.90; p = 0.006) predicted procedure time ≥ 90 min. A scoring system was created to predict prolonged ESD procedure time and was externally validated, with AUC 0.78 (95% CI 0.73–0.83).
This study demonstrates the effects of multiple risk factors on resection outcomes and procedure time in colorectal ESD. Tattoo placement and attempted EMR should be avoided for lesions being considered for ESD.
KeywordsEndoscopic submucosal dissection Endoscopic resection Colorectal polyp Colorectal neoplasia Therapeutic endoscopy
Analysis of variance
Area under the receiver operating characteristics curve
Endoscopic mucosal resection
Endoscopic submucosal dissection
Laterally spreading tumor
Laterally spreading tumor, granular type
- LST-G (mixed)
Laterally spreading tumor, granular type, nodular mixed type
- LST-G (uni)
Laterally spreading tumor, granular type, homogeneous type
Laterally spreading tumor, non-granular type
- LST-NG (FE)
Laterally spreading tumor, non-granular type, flat-elevated type
- LST-NG (PD)
Laterally spreading tumor, non-granular type, pseudo-depressed type
Narrow band imaging
PSG, MD (study concept and design, acquisition of data, analysis and interpretation of data, and drafting of manuscript). PJ, MD (analysis and interpretation of data, critical revision of manuscript). TRO, MD, PhD (analysis and interpretation of data). NT, MD, PhD (analysis and interpretation of data). KS, MD, PhD (analysis and interpretation of data). CCT, MD, MHES (study concept and design, analysis and interpretation of data, and critical revision of manuscript). HA, MD, PhD (study concept and design, acquisition of data, analysis and interpretation of data, critical revision of manuscript, and study supervision).
Compliance with ethical standards
Christopher C. Thompson: Boston Scientific (Consultant) and Olympus (Consultant, Research Support). Hiroyuki Aihara: Boston Scientific (Consultant), Olympus (Consultant), and Fujifilm Medical Systems (Consultant). Drs. Ge, Jirapinyo, Ohya, Tamai, and Sumiyama have no conflicts of interest or financial ties to disclose.