Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience

Abstract

Objective

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.

Design

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.

Results

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).

Conclusion

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.

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Abbreviations

ANOVA:

Analysis of variance

AUROC:

Area under the receiver operating characteristics curve

CI:

Confidence interval

EMR:

Endoscopic mucosal resection

ESD:

Endoscopic submucosal dissection

EUS:

Endoscopic ultrasound

LST:

Laterally spreading tumor

LST-G:

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

LST-NG:

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

NBI:

Narrow band imaging

SD:

Standard deviation

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Affiliations

Authors

Contributions

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).

Corresponding author

Correspondence to Hiroyuki Aihara.

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Disclosures

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.

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Ge, P.S., Jirapinyo, P., Ohya, T.R. et al. Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience. Surg Endosc 33, 4016–4025 (2019). https://doi.org/10.1007/s00464-019-06691-4

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Keywords

  • Endoscopic submucosal dissection
  • Endoscopic resection
  • Colorectal polyp
  • Colorectal neoplasia
  • Therapeutic endoscopy