Skip to main content

Advertisement

SpringerLink
Log in

Factors affecting the technical difficulty and clinical outcome of endoscopic submucosal dissection for colorectal tumors

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Endoscopic submucosal dissection (ESD) for colorectal tumors is technically difficult due to the anatomy of the large intestine, with its narrow lumen, thin walls, and redundancy. Here, we assessed factors associated with incomplete resection and difficult colorectal ESD.

Methods

Between November 2009 and April 2013, we performed ESD on 151 consecutive colorectal tumors in 147 patients. We evaluated the clinical outcomes of all cases and conducted multiple logistic regression analysis of the following factors related to incomplete resection and difficult procedure: age, gender, location (right colon, left colon or rectum), tumor size (diameter ≥40 or <40 mm), operation time, morphology [granular-type laterally spreading tumor (LST-G), non-granular-type laterally spreading tumor (LST-NG), or protruded type], fibrosis, and paradoxical movement during the procedure. A procedure that required more than 120 min was defined as a difficult colorectal ESD.

Results

Average tumor size was 32.1 ± 10.7 mm, and the average procedure length was 71.8 ± 49.5 min. The rate of en bloc resection was 94.7 %, while that of en bloc curative resection was 86.8 %. Perforation occurred in 1.3 % of the ESD procedures. Multivariate logistic regression analysis revealed that only severe fibrosis [odds ratio (OR) 4.51; 95 % confidence interval (CI) 1.36–14.91, p = 0.014] contributed to incomplete resection and that a tumor size exceeding 40 mm (OR 5.73 [95 % CI 1.66–19.74], p = 0.006), severe fibrosis (OR 23.31 [95 % CI 6.59–82.54], p < 0.001), and paradoxical movement (OR 4.26 [95 % CI 1.11–16.44], p = 0.035) were independent factors exacerbating the difficulty of colorectal ESD.

Conclusions

Severe fibrosis contributed to both incomplete resection and difficult colorectal ESD. Larger tumor size and paradoxical movement during the procedure were independent factors contributing to the difficulty of colorectal ESD. These factors might enable endoscopists to develop strategies for treating colorectal ESD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Niimi K, Fujishiro M, Kodashima S, Goto O, Ono S, Hirano K, Minatsuki C, Yamamichi N, Koike K (2010) Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 42:723–729

    Article  PubMed  CAS  Google Scholar 

  2. Toyonaga T, Man-i M, East JE, Nishino E, Ono W, Hirooka T, Ueda C, Iwata Y, Sugiyama T, Dozaiku T, Hirooka T, Fujita T, Inokuchi H, Azuma T (2013) 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. Surg Endosc 27:1000–1008

    Article  PubMed  PubMed Central  Google Scholar 

  3. Tanabe S, Ishido K, Higuchi K, Sasaki T, Katada C, Azuma M, Naruke A, Kim M, Koizumi W (2014) Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a retrospective comparison with conventional endoscopic resection in a single center. Gastric cancer: official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association 17(1):130–136

    Article  Google Scholar 

  4. Isomoto H, Nishiyama H, Yamaguchi N, Fukuda E, Ishii H, Ikeda K, Ohnita K, Nakao K, Kohno S, Shikuwa S (2009) Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 41:679–683

    Article  PubMed  CAS  Google Scholar 

  5. Sakamoto T, Saito Y, Fukunaga S, Nakajima T, Matsuda T (2011) Learning curve associated with colorectal endoscopic submucosal dissection for endoscopists experienced in gastric endoscopic submucosal dissection. Dis Colon Rectum 54:1307–1312

    Article  PubMed  Google Scholar 

  6. Kim ES, Cho KB, Park KS, Lee KI, Jang BK, Chung WJ, Hwang JS (2011) Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy 43:573–578

    Article  PubMed  CAS  Google Scholar 

  7. Nakajima T, Saito Y, Tanaka S, Iishi H, Kudo SE, Ikematsu H, Igarashi M, Saitoh Y, Inoue Y, Kobayashi K, Hisasbe T, Matsuda T, Ishikawa H, Sugihara KI (2013) Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc. 27(9):3262–3270

    Article  PubMed  Google Scholar 

  8. Saito Y, Uraoka T, Yamaguchi Y, Hotta K, Sakamoto N, Ikematsu H, Fukuzawa M, Kobayashi N, Nasu J, Michida T, Yoshida S, Ikehara H, Otake Y, Nakajima T, Matsuda T, Saito D (2010) A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 72:1217–1225

    Article  PubMed  Google Scholar 

  9. Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, Yamamichi N, Tateishi A, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2007) Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association 5:678–683 quiz 645

    Article  Google Scholar 

  10. Lee EJ, Lee JB, Choi YS, Lee SH, Lee DH, Kim do S, Youk EG (2012) Clinical risk factors for perforation during endoscopic submucosal dissection (ESD) for large-sized, nonpedunculated colorectal tumors. Surg Endosc 26:1587–1594

    Article  PubMed  Google Scholar 

  11. Matsumoto A, Tanaka S, Oba S, Kanao H, Oka S, Yoshihara M, Chayama K (2010) Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 45:1329–1337

    Article  PubMed  Google Scholar 

  12. Inada Y, Yoshida N, Kugai M, Kamada K, Katada K, Uchiyama K, Handa O, Takagi T, Konishi H, Yagi N, Naito Y, Wakabayashi N, Yanagisawa A, Itoh Y (2013) Prediction and treatment of difficult cases in colorectal endoscopic submucosal dissection. Gastroenterol Res Pract 2013:523084

    Article  PubMed  PubMed Central  Google Scholar 

  13. Yoshida N, Wakabayashi N, Kanemasa K, Sumida Y, Hasegawa D, Inoue K, Morimoto Y, Kashiwa A, Konishi H, Yagi N, Naito Y, Yanagisawa A, Yoshikawa T (2009) Endoscopic submucosal dissection for colorectal tumors: technical difficulties and rate of perforation. Endoscopy 41:758–761

    Article  PubMed  CAS  Google Scholar 

  14. Yoon JY, Kim JH, Lee JY, Hong SN, Lee SY, Sung IK, Park HS, Shim CS, Han HS (2013) Clinical outcomes for patients with perforations during endoscopic submucosal dissection of laterally spreading tumors of the colorectum. Surg Endosc 27:487–493

    Article  PubMed  Google Scholar 

  15. Tanaka S, Oka S, Chayama K (2008) Colorectal endoscopic submucosal dissection: present status and future perspective, including its differentiation from endoscopic mucosal resection. J Gastroenterol 43:641–651

    Article  PubMed  Google Scholar 

  16. Inoue H (2003) The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon. Gastrointest Endosc 58:S3–43

    Article  Google Scholar 

  17. Saito Y, Kawano H, Takeuchi Y, Ohata K, Oka S, Hotta K, Okamoto K, Homma K, Uraoka T, Hisabe T, Chang DK, Zhou PH (2012) Current status of colorectal endoscopic submucosal dissection in Japan and other Asian countries: progressing towards technical standardization. Dig Endosc: official journal of the Japan Gastroenterological Endoscopy Society 24(Suppl 1):67–72

    Article  Google Scholar 

  18. Lee EJ, Lee JB, Lee SH, Kim do S, Lee DH, Lee DS, Youk EG (2013) Endoscopic submucosal dissection for colorectal tumors—1,000 colorectal ESD cases: one specialized institute’s experiences. Surg Endosc 27:31–39

    Article  PubMed  Google Scholar 

  19. (1983) General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Part II. Histopathological classification. Japanese Research Society for Cancer of the Colon and Rectum. Jpn Surg 13:574-598

  20. Kitajima K, Fujimori T, Fujii S, Takeda J, Ohkura Y, Kawamata H, Kumamoto T, Ishiguro S, Kato Y, Shimoda T, Iwashita A, Ajioka Y, Watanabe H, Watanabe T, Muto T, Nagasako K (2004) Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol 39:534–543

    Article  PubMed  Google Scholar 

  21. Nishiyama H, Isomoto H, Yamaguchi N, Ishii H, Fukuda E, Machida H, Nakamura T, Ohnita K, Shikuwa S, Kohno S, Nakao K (2010) Endoscopic submucosal dissection for laterally spreading tumours of the colorectum in 200 consecutive cases. Surg Endosc 24:2881–2887

    Article  PubMed  Google Scholar 

  22. Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, Yoshida S, Chayama K (2007) Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 66:100–107

    Article  PubMed  Google Scholar 

  23. Oka S, Tanaka S, Takata S, Kanao H, Chayama K (2012) Usefulness and safety of SB knife Jr in endoscopic submucosal dissection for colorectal tumors. Dig Endosc: official journal of the Japan Gastroenterological Endoscopy Society 24(Suppl 1):90–95

    Article  Google Scholar 

  24. Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, Kikuchi T, Fu KI, Sano Y, Saito D (2007) Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 66:966–973

    Article  PubMed  Google Scholar 

  25. Hawari R, Pasricha PJ (2007) Going for the loop: a unique overtube for the difficult colonoscopy. J Clin Gastroenterol 41:138–140

    Article  PubMed  Google Scholar 

  26. Sato K, Yokouchi Y, Saida Y, Ito S, Kitagawa T, Maetani I (2012) A small cell neuroendocrine carcinoma of the rectum diagnosed by colorectal endoscopic submucosal dissection. J Gastrointest Liver Dis JGLD 21:128

    Google Scholar 

  27. Tanaka S, Terasaki M, Kanao H, Oka S, Chayama K (2012) Current status and future perspectives of endoscopic submucosal dissection for colorectal tumors. Dig Endosc: official journal of the Japan Gastroenterological Endoscopy Society 24(Suppl 1):73–79

    Article  Google Scholar 

  28. Tamegai Y, Saito Y, Masaki N, Hinohara C, Oshima T, Kogure E, Liu Y, Uemura N, Saito K (2007) Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 39:418–422

    Article  PubMed  CAS  Google Scholar 

  29. Yoshida N, Yagi N, Naito Y, Yoshikawa T (2010) Safe procedure in endoscopic submucosal dissection for colorectal tumors focused on preventing complications. World J Gastroenterol WJG 16:1688–1695

    Article  Google Scholar 

  30. Ohya T, Ohata K, Sumiyama K, Tsuji Y, Koba I, Matsuhashi N, Tajiri H (2009) Balloon overtube-guided colorectal endoscopic submucosal dissection. World J Gastroenterol WJG 15:6086–6090

    Article  Google Scholar 

Download references

Acknowledgments

The authors wish to thank the endoscopy staff for their assistance.

Disclosures

Koichiro Sato, Sayo Ito, Tomoyuki Kitagawa, Mitsuru Kato, Kenji Tominaga, Takeshi Suzuki, and Iruru Maetani have no conflict of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology , Department of Internal Medicine, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan

    Koichiro Sato, Sayo Ito, Tomoyuki Kitagawa, Mitsuru Kato, Kenji Tominaga, Takeshi Suzuki & Iruru Maetani

Authors
  1. Koichiro Sato
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sayo Ito
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tomoyuki Kitagawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mitsuru Kato
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kenji Tominaga
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Takeshi Suzuki
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Iruru Maetani
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Koichiro Sato.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sato, K., Ito, S., Kitagawa, T. et al. Factors affecting the technical difficulty and clinical outcome of endoscopic submucosal dissection for colorectal tumors. Surg Endosc 28, 2959–2965 (2014). https://doi.org/10.1007/s00464-014-3558-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-014-3558-y

Keywords

Search

Navigation