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      • Record: found
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      The efficacy of the pocket-creation method for cases with severe fibrosis in colorectal endoscopic submucosal dissection

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          Abstract

          Background and study aims

           Severe fibrosis poses a challenge in colorectal endoscopic submucosal dissection (ESD). Recently, the pocket-creation method (PCM) has been developed for overcoming various difficulties of ESD. A specific tapered hood is used for adequate traction in the PCM, and endoscopic operability becomes stable in the pocket. In this study, we investigated the efficacy of the PCM in ESD for cases with severe fibrosis.

          Patients and methods 

          We retrospectively reviewed 1000 consecutive colorectal ESD cases (April 2006 to January 2017). Since 2016, the PCM was performed in 58 cases. The indications for ESD included (1) tumors ≥ 20 mm in size diagnosed as intramucosal cancer or high-grade dysplasia and part of T1a cancer using magnifying endoscopic examinations and (2) tumors that appeared impossible to resect with endoscopic mucosal resection because of suspected fibrosis. We identified 120 cases with severe fibrosis and compared them to cases without severe fibrosis. Additionally, the 120 severe fibrosis cases were divided into the PCM and non-PCM groups. En bloc resection, procedure time, discontinuation, and complications were analyzed between these 2 groups.

          Results

           Among all 1000 ESDs, severe fibrosis and discontinuation rates were 12.0 % (120 cases) and 1.8 % (18 cases), respectively. Regarding the comparison between cases with severe fibrosis and with no severe fibrosis, there were significant differences about en bloc resection rate (78.3 % vs. 95.7 %, P  < 0.001), discontinuance rate (12.5 % vs. 0.3 %, P  < 0.001), and perforation rate (8.3 % vs. 2.6 %, P  = 0.001). Among the 120 cases with severe fibrosis, 21 and 99 cases were in the PCM and non-PCM groups, respectively. The PCM group had a higher en bloc resection rate (95.2 vs. 74.7, P  =  0.03), a shorter mean procedure time (min) (79.6 ± 26.5 vs. 118.8 ± 71.0, P  = 0.001), and no cases of discontinuation. An analysis of the interobserver agreement for the diagnosis of severe fibrosis among the 3 endoscopists showed kappa values of > 0.6.

          Conclusions

           In cases with severe fibrosis, the PCM with ESD improved en bloc resection rates and shortened the procedure time compared to the conventional non-PCM method. Additionally, the PCM reduced the discontinuation rate.

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          Most cited references21

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

          Cláudia A. N. Kobayashi, Junichirou Nasu, Yuichiro Yamaguchi … (2010)
          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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            Colorectal tumours and pit pattern.

            Rafael T Nakajima, S Kudo, H Kusaka … (1994)
            To investigate the morphological and histopathological associations between an individual pit seen on stereomicroscopy or magnifying colonoscopy and an individual crypt seen in histological sections; and to examine these associations in colorectal tumours. Fourteen thousand and twenty three cases were examined by colonoscope at Akita Red Cross Hospital. The surface mucosal pits of the lesions were observed using a magnifying endoscope in vivo and the pits of the extracted specimens were observed in vitro using a stereo microscope. Histological diagnoses were determined by light microscopy: the pit patterns in 100 glands were analysed. Pit pattern was classified into seven principal types: (1) normal round pit; (2) small round pit; (3) small asteroid pit; (4) large asteroid pit; (5) oval pit; (6) gyrus-like pit; and (7) non-pit. There was a correlation between pit pattern and the structure of the underlying crypt or gland. Furthermore, there was an association between pit pattern and the histology of the cells in the gland. Macroscopically, types 3, 4, 5, and 6 were common in protruding lesions. Type 2 was common in depressed lesions. The non-pit pattern was recognised in both. The depressed lesions had invaded the deeper layers more rapidly than protruding lesions. There were associations between individual pits and crypts. The branching carcinoma gland is thought to be the result of malignant transformation of the adenoma gland. The straight carcinoma gland is thought to result from the normal gland becoming malignant. The gland of the small round pit is thought to change from normal to the straight carcinoma gland via malignant transformation.
            Article 0 comments Cited 95 times – based on 0 reviews     Review now
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              Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization.

              Ritsuo Mouri, Shinji Tanaka, Shiro Oka … (2007)
              Endoscopic submucosal dissection (ESD) has been positively applied to and gradually standardized for early stomach cancer, particularly in Japan. However, because it is technically difficult to perform ESD of the colon, ESD is not a commonly used technique. The aim of this study was to evaluate the possibility of standardizing colorectal ESD. ESD was performed at the Department of Endoscopy, Hiroshima University Hospital. Time required for ESD, rate of complete en bloc resection, complication, and postoperative local persistence and recurrence were investigated retrospectively in 70 cases of colorectal neoplasia, wherein the lesion was more than 20 mm in diameter. All lesions were resected by ESD. The average (+/-SD) time required for ESD was 70.5+/-45.9 minutes (range, 15-180 minutes), and the histologic rate of complete en bloc resection was 80.0% (56/70). With regard to complication, 1.4% of cases of postoperative hemorrhage (1/70) and 10.0% of cases of perforation (7/70) were observed in total. The rate of perforation was investigated with respect to the type of knife used for ESD and the period after the induction of ESD. The rate of perforation markedly decreased with the practice of the technique. Moreover, the rate of perforation was high when an insulated-tip diathermic knife was used; practicing this technique was insufficient to reduce the rate of perforation. The average duration of follow-up was 614+/-289.5 days, and no case of local persistence and recurrence or metastasis was observed. The ESD technique depends on the level of each skill of each colonoscopist. With regard to ESD of the colon, complication, eg, perforation, could be decreased by sufficient practice and selection of an appropriate knife. It is suggested that, in the near future, ESD will be standardized for the colon.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Endosc Int Open
                Journal ID (iso-abbrev): Endosc Int Open
                Journal ID (doi): 10.1055/s-00025476
                Title: Endoscopy International Open
                Publisher: © Georg Thieme Verlag KG (Stuttgart · New York )
                ISSN (Print): 2364-3722
                ISSN (Electronic): 2196-9736
                Publication date (Print): August 2018
                Publication date (Electronic): 03 August 2018
                Volume: 6
                Issue: 8
                Pages: E975-E983
                Affiliations
                [1 ]Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
                [2 ]Gastroenterology Unit, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
                [3 ]Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
                [4 ]Department of Surgery, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
                Author notes
                Corresponding author Naohisa Yoshida, MD, PhD Department of Molecular Gastroenterology and Hepatology Kyoto Prefectural University of Medicine, Graduate School of Medical Science 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566Japan+81-75-251-0710 naohisa@ 123456koto.kpu-m.ac.jp
                Article
                DOI: 10.1055/a-0593-5818
                PMC ID: 6075949
                PubMed ID: 30083587
                SO-VID: a71263c2-d40f-43b1-8d47-1990b8c1c0ec
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

                History
                Date received : 10 August 2017
                Date accepted : 26 February 2018
                Categories
                Subject: Original article

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