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EFFECTIVENESS OF ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) AS AN ALTERNATIVE TO TRADITIONAL SURGERY FOR REMOVAL OF LARGE ADENOMATOUS POLYPS AND EARLY MALIGNANCIES OF THE COLON AND RECTUM
Mainor R Antillon, Wilson P Pais, Marc L Miller, Alberto A Diaz-Arias, Daphne Antillon, Megan R Kowal, Jamal A Ibdah, John B Marshall
Division of Gastroenterology, University of Missouri, Columbia, MO, USA
BACKGROUND: Conventional methods of removing large polyps from the colorectum have included piecemeal polypectomy and surgical resection. Endoscopic submucosal dissection (ESD), a type of intralumenal endoscopic surgery, was recently developed in Japan for en-bloc removal of GI tumors. The technique employs an electrosurgical knife to dissect the submucosal layer beneath the lesion, and is capable of removing en-bloc much larger tumors than the older technique of endoscopic mucosal resection (EMR).
OBJECTIVE: Our purpose was to assess the effectiveness and safety of ESD for the removal of large lateral spreading adenomas and early cancers of the colon and rectum.
METHODS: Retrospective analysis from chart audits of patients who underwent ESD of lesions from the colorectum at our tertiary care university hospital in the U.S. over the period June 2006 to September 2007.
RESULTS: 41 patients with large lateral spreading benign polyps and early malignancies of the colon and rectum underwent ESD treatment. One endoscopist (MRA) performed all procedures. The electrosurgical knife used was the conventional (non-insulated tip) needle knife (CNK), which is readily available in the U.S. for ERCP. The 30 benign lesions in our series included 21 from the colon and 9 from the rectum, 5 of which involved the anal canal. There were 11 early colorectal cancers, 2 of which involved the anal canal. Procedural success was 100%. The benign colorectal polyps removed with ESD (n=30) ranged in size from 2-cm to 15-cm (mean 5-cm). The early colorectal cancers removed with ESD ranged in size from 1.5-cm to 6-cm (mean 3.5-cm). The success rate of en-bloc removal for benign colorectal lesions (n=30) was 87%; free margins were present in 80%. The success rate of en-bloc removal of the cancerous lesions (n=11) was 91%; free margins were present in 73%. All 7 patients with anal canal involvement had successful tumor removal. All avoided colostomy, and continence was preserved. The complications in our 41 patients included 4 perforations (1 required surgery; 3 resolved medically) and 1 patient with bleeding which required transfusion (2 units packed RBCs). Mean length of hospitalization for benign and cancerous colorectal ESDs (n=41) was 0.9 days.
CONCLUSIONS: ESD, using a CNK, appears to be an effective and safe alternative to surgery for the removal of large lateral spreading colorectal polyps and early colorectal cancers. The technique is also successful when there is anal canal involvement.