Predictive Factors of Mild and Severe Fibrosis in Colorectal Endoscopic Submucosal Dissection

  • Hideyuki ChibaEmail author
  • Jun Tachikawa
  • Jun Arimoto
  • Keiichi Ashikari
  • Hiroki Kuwabara
  • Michiko Nakaoka
  • Toru Goto
  • Ken Ohata
  • Atsushi Nakajima
Original Article


Background and Study Aims

Varying degrees of fibrosis in colorectal endoscopic submucosal dissection (ESD) make the procedure difficult. Consensus on the predictive factors of fibrosis degree (mild or severe) has not been established. We conducted a study to identify the predictive factors and to examine the feasibility of ESD for fibrotic lesions.

Patients and Methods

We included 518 patients who had undergone ESD for 558 lesions from April 2012–September 2018. Patients were classified into fibrosis or no-fibrosis groups, and logistic regression analysis was performed to identify predictive factors of fibrosis. Subgroup analyses were performed for fibrosis degree.


The total incidence of fibrosis was 21.1% (mild: 14.1%; severe: 7.1%). Although the curative resection rate (free margin: invasion depth less than 1000 μm: no lymphatic invasion, vascular involvement) was lower in the fibrosis group compared with the control (80.7% vs. 97.6%), neither the en bloc resection rate (99.1% vs. 100%) nor incidence of perforation (0.9% vs. 0.2%) differed between the two groups. Multivariate analysis revealed that a cecal location, preoperative biopsy, straddling fold, laterally spreading tumor–non-granular-pseudo-depressed (LST-NG-PD) type were predictive of mild fibrosis. The presence of a straddling fold and a protruded lesion were independent predictive factors of severe fibrosis.


We identified the predictive factors of mild and severe fibrosis. It is preferable that a more experienced physician performs ESD for the lesions with F2 fibrosis.


Fibrosis Endoscopic submucosal dissection Colorectal cancer Complication 


Compliance with Ethical Standards

Conflict of interest

The authors declare they have no conflict of interest.

Ethical approval

The study was conducted in accordance with the principles laid down in the Declaration of Helsinki, and with the approval of the Institutional Review Board of our hospital (No.18-45).


  1. 1.
    Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65:87–108.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366:687–696.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Gorgun E, Benlice C, Abbas MA, et al. Experience in colon sparing surgery in North America: advanced endoscopic approaches for complex colorectal lesions. Surg Endosc. 2018;32:3114–3121.CrossRefPubMedGoogle Scholar
  4. 4.
    Sauer M, Hildenbrand R, Oyama T, et al. Endoscopic submucosal dissection for flat or sessile colorectal neoplasia >  20 mm: a European single-center series of 182 cases. Endosc Int Open. 2016;4:E895–E900.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Chiba H, Ohata K, Ohno A, et al. Perforation with retroperitoneal emphysema after endoscopic submucosal dissection for a rectal carcinoid tumor. Endoscopy. 2010;42:E85–E86.CrossRefPubMedGoogle Scholar
  6. 6.
    Arimoto J, Higurashi T, Chiba H, et al. Continued use of a single antiplatelet agent does not increase the risk of delayed bleeding after colorectal endoscopic submucosal dissection. Dig Dis Sci. 2018;63:218–227.CrossRefPubMedGoogle Scholar
  7. 7.
    Arimoto J, Higurashi T, Kato S, et al. Risk factors for post-colorectal endoscopic submucosal dissection (ESD) coagulation syndrome: a multicenter, prospective, observational study. Endosc Int Open. 2018;6:E342–E349.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Chiba H, Ohata K, Tachikawa J, et al. Delayed bleeding after colorectal endoscopic submucosal dissection: When is emergency colonoscopy needed? Dig Dis Sci. 2018;64:880–887.CrossRefPubMedGoogle Scholar
  9. 9.
    Makino T, Kanmura S, Sasaki F, et al. Preoperative classification of submucosal fibrosis in colorectal laterally spreading tumors by endoscopic ultrasonography. Endosc Int Open. 2015;3:E363–E367.CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Imai K, Hotta K, Yamaguchi Y, et al. Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training. Gastrointest Endosc. 2016;83:954–962.CrossRefPubMedGoogle Scholar
  11. 11.
    Matsumoto A, Tanaka S, Oba S, et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol. 2010;45:1329–1337.CrossRefPubMedGoogle Scholar
  12. 12.
    Tamegai Y, Kisihara T, Fukunaga Y, et al. Endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis in the submucosal layer. Gastroenterol Endosc. 2015;57:259–271.Google Scholar
  13. 13.
    Tanaka S, Kashida H, Saito Y, et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc. 2015;27:417–434.CrossRefGoogle Scholar
  14. 14.
    Uraoka T, Saito Y, Matsuda T, et al. Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut. 2006;55:1592–1597.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Hotta K, Yamaguchi Y, Saito Y, et al. Current opinions for endoscopic submucosal dissection for colorectal tumors from our experiences: indications, technical aspects and complications. Dig Endosc. 2012;24:110–116.CrossRefPubMedGoogle Scholar
  16. 16.
    Watanabe T, Itabashi M, Shimada Y, et al. Japanese society for cancer of the colon and rectum (JSCCR) guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol. 2015;20:207–239.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Mizushima T, Kato M, Iwanaga I, et al. Technical difficulty according to location, and risk factors for perforation, in endoscopic submucosal dissection of colorectal tumors. Surg Endosc. 2015;29:133–139.CrossRefGoogle Scholar
  18. 18.
    Kim ES, Cho KB, Park KS, et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy. 2011;43:573–578.CrossRefPubMedGoogle Scholar
  19. 19.
    Isomoto H, Nishiyama H, Yamaguchi N, et al. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy. 2009;41:679–683.CrossRefPubMedGoogle Scholar
  20. 20.
    Hotta K, Oyama T, Shinohara T, et al. Learning curve for endoscopic submucosal dissection of large colorectal tumors. Dig Endosc. 2010;22:302–306.CrossRefPubMedGoogle Scholar
  21. 21.
    Seo M, Yang DH, Kim J, et al. Clinical outcomes of colorectal endoscopic submucosal dissection and risk factors associated with piecemeal resection. Turk J Gastroenterol. 2018;29:473–480.CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Iacopini F, Saito Y, Bella A, et al. Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty. Endosc Int Open. 2017;5:E839–E846.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Pérez-Cuadrado-Robles E, Snauwaert C, Moreels TG, et al. Risk factors for conversion to snare resection during colorectal endoscopic submucosal dissection in an expert Western center. Endoscopy. 2019;51:152–160.CrossRefPubMedGoogle Scholar
  24. 24.
    Suzuki T, Hara T, Kitagawa Y, et al. Feasibility of endoscopic submucosal dissection for cecal lesions. Scand J Gastroenterol. 2018;53:359–364.CrossRefPubMedGoogle Scholar
  25. 25.
    Kim HG, Thosani N, Banerjee S, et al. Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions. Gastrointest Endosc. 2015;81:204–213.CrossRefPubMedGoogle Scholar
  26. 26.
    Fukunaga S, Nagami Y, Shiba M, et al. Impact of preoperative biopsy sampling on severe submucosal fibrosis on endoscopic submucosal dissection for colorectal laterally spreading tumors: a propensity score analysis. Gastrointest Endosc. 2019;89:470–478.CrossRefPubMedGoogle Scholar
  27. 27.
    Toyonaga T, Man-i M, Fujita T, et al. Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum. Endoscopy. 2010;42:714–722.CrossRefPubMedGoogle Scholar
  28. 28.
    Toyonaga T, Tanaka S, Man-I M, et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open. 2015;3:E246–E251.CrossRefPubMedCentralPubMedGoogle Scholar
  29. 29.
    Chiba H, Ohata K, Takita M, et al. Double-tunnel method for treatment of colorectal lesions with severe fibrosis with endoscopic submucosal dissection. Endoscopy. 2018;50:E168–E169.CrossRefPubMedGoogle Scholar
  30. 30.
    Fujihara S, Mori H, Kobara H, et al. The efficacy and safety of prophylactic closure for a large mucosal defect after colorectal endoscopic submucosal dissection. Oncol Rep. 2013;30:85–90.CrossRefPubMedGoogle Scholar
  31. 31.
    Saito Y, Uraoka T, Yamaguchi Y, et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest. Endosc. 2010;72:1217–1225.CrossRefPubMedGoogle Scholar
  32. 32.
    Ohata K, Nonaka K, Minato Y, et al. Endoscopic submucosal dissection for large colorectal tumor in a Japanese general hospital. J Oncol. 2013;2013:218670.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Ohata K, Ito T, Chiba H, et al. Effective training system in colorectal endoscopic submucosal dissection. Dig Endosc. 2012;24:84–89.CrossRefPubMedGoogle Scholar
  34. 34.
    Chiba H, Tachikawa J, Kurihara D, et al. Safety and efficacy of simultaneous colorectal ESD for large synchronous colorectal lesions. Endosc Int Open. 2017;5:E595–E602.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of GastroenterologyOmori Red Cross HospitalOta-KuJapan
  2. 2.Department of Gastroenterology and HepatologyYokohama City University School of MedicineYokohamaJapan
  3. 3.Department of GastroenterologyNTT Medical Center TokyoShinagawa-KuJapan

Personalised recommendations