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      Endoscopic Mucosal Resection with Circumferential Mucosal Incision for Colorectal Neoplasms: Comparison with Endoscopic Submucosal Dissection and between Two Endoscopists with Different Experiences

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          Abstract

          Background/Aims

          Endoscopic mucosal resection with circumferential mucosal incision (CMI-EMR) may offer benefits comparable to those of endoscopic submucosal dissection (ESD), while requiring less technical proficiency than ESD.

          Methods

          We retrospectively compared the outcomes of CMI-EMR ( n=34) and size-matched ESD ( n=102), which were performed by a Korean endoscopist for colorectal epithelial lesions of 20–35 mm. Procedural parameters of CMI-EMRs performed by an American ESD novice ( n=30) were compared with those performed by the Korean endoscopist.

          Results

          The lesion size was 22.3±3.9 mm and 22.9±2.4 mm in the CMI-EMR and size-matched ESD groups, respectively ( p=0.730). The resection time was 12.7±7.0 minutes in the CMI-EMR group and 45.6±30.1 minutes in the ESD group ( p<0.001). The en bloc resection rate was 94.1% in the CMI-EMR group and 100% in the ESD group ( p=0.061). There were no differences in the en bloc resection and complication rates of CMI-EMRs between a Korean and an American endoscopist.

          Conclusions

          For the treatment of moderate-size colorectal lesions, CMI-EMR showed a trend toward lower en bloc resection rate, but required shorter procedure time than ESD. CMI-EMR outcomes were similar when performed by a Korean ESD expert and an American ESD novice.

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          Most cited references23

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          A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video).

          Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, although it is not widely used in the colorectum because of technical difficulty. To examine the current status of colorectal ESDs at specialized endoscopic treatment centers. Multicenter cohort study using a prospectively completed database at 10 specialized institutions. From June 1998 to February 2008, 1111 colorectal tumors in 1090 patients were treated by ESD. Tumor size, macroscopic type, histology, procedure time, en bloc and curative resection rates and complications. Included in the 1111 tumors were 356 tubular adenomas, 519 intramucosal cancers, 112 superficial submucosal (SM) cancers, 101 SM deep cancers, 18 carcinoid tumors, 1 mucosa-associated lymphoid tissue lymphoma, and 4 serrated lesions. Macroscopic types included 956 laterally spreading tumors, 30 depressed, 62 protruded, 44 recurrent, and 19 SM tumors. The en bloc and curative resection rates were 88% and 89%, respectively. The mean procedure time ± standard deviation was 116 ± 88 minutes with a mean tumor size of 35 ± 18 mm. Perforations occurred in 54 cases (4.9%) with 4 cases of delayed perforation (0.4%) and 17 cases of postoperative bleeding (1.5%). Two immediate perforations with ineffective endoscopic clipping and 3 delayed perforations required emergency surgery. Tumor size of 50 mm or larger was an independent risk factor for complications, whereas a large number of ESDs performed at an institution decreased the risk of complications. No long-term outcome data. ESD performed by experienced endoscopists is an effective alternative treatment to surgery, providing high en bloc and curative resection rates for large superficial colorectal tumors. Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.
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            JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection.

            Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence-based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas.
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              Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection.

              Endoscopic submucosal dissection (ESD) has recently been applied to the treatment of superficial colorectal cancer. Clinical outcomes compared with conventional endoscopic mucosal resection (EMR) have not been determined so our aim was to compare the effectiveness of ESD with conventional EMR for colorectal tumors >or=20 mm. This was a retrospective case-controlled study performed at the National Cancer Center Hospital in Tokyo, Japan involving 373 colorectal tumors >or=20 mm determined histologically to be curative resections. Data acquisition was from a prospectively completed database. We evaluated histology, tumor size, procedure time, en bloc resection rate, recurrence rate, and associated complications for both the ESD and EMR groups. A total of 145 colorectal tumors were treated by ESD and another 228 were treated by EMR. ESD was associated with a longer procedure time (108 +/- 71 min/29 +/- 25 min; p < 0.0001), higher en bloc resection rate (84%/33%; p < 0.0001) and larger resected specimens (37 +/- 14 mm/28 +/- 8 mm; p = 0.0006), but involved a similar percentage of cancers (69%/66%; p = NS). There were three (2%) recurrences in the ESD group and 33 (14%) in the EMR group requiring additional EMR (p < 0.0001). The perforation rate was 6.2% (9) in the ESD group and 1.3% (3) in the EMR group (p = NS) with delayed bleeding occurring in 1.4% (2) and 3.1% (7) of the procedures (p = NS), respectively, as all complications were effectively treated endoscopically. Despite its longer procedure time and higher perforation rate, ESD resulted in higher en bloc resection and curative rates compared with EMR and all ESD perforations were successfully managed by conservative endoscopic treatment.
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                Author and article information

                Journal
                Clin Endosc
                Clin Endosc
                CE
                Clinical Endoscopy
                Korean Society of Gastrointestinal Endoscopy
                2234-2400
                2234-2443
                July 2017
                7 March 2017
                : 50
                : 4
                : 379-387
                Affiliations
                [1 ]Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
                [2 ]Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
                [3 ]Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, Department of Gastroenterology, VA Palo Alto Health Care System, Palo Alto, CA, USA
                Author notes
                Co-correspondence: Dong-Hoon Yang Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-5809, Fax: +82-2-3010-6517, E-mail: dhyang@ 123456amc.seoul.kr
                Shai Friedland Department of Gastroenterology, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304, USA Tel: +1-650-493-5000, x64800 Fax: +1-650-498-6323, E-mail: shai_friedland@ 123456yahoo.com
                Article
                ce-2016-058
                10.5946/ce.2016.058
                5565045
                28264251
                0162cd66-225d-4e97-a3ec-453973d95574
                Copyright © 2017 Korean Society of Gastrointestinal Endoscopy

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 20 April 2016
                : 22 January 2017
                : 25 January 2017
                Categories
                Original Article

                Radiology & Imaging
                neoplasms,colon,rectum,endoscopic mucosal resection,endoscopic submucosal dissection

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