Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis

Abstract

Background and study aims: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows en-bloc resection of gastrointestinal tumor. We systematically review the medical literature in order to evaluate the safety and efficacy of colorectal ESD. Patients and methods: We performed a comprehensive literature search of MEDLINE, EMBASE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of colorectal ESD. Results: Included in this study were 13833 tumors in 13603 patients (42 % female) who underwent colorectal ESD between 1998 and 2014. The R0 resection rate was 83 % (95 % CI, 80 – 86 %) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in continent (P = 0.004), study design (P = 0.04), duration of the procedure (P = 0.009), and, marginally, by average tumor size (P = 0.09). Endoscopic en bloc and curative resection rates were 92 % (95 % CI, 90 – 94 %) and 86 % (95 % CI, 80 – 90 %), respectively. The rates of immediate and delayed perforation were 4.2 % (95 % CI, 3.5 – 5.0 %) and 0.22 % (95 % CI, 0.11 – 0.46 %), respectively, while rates of immediate and delayed major bleeding were 0.75 % (95 % CI, 0.31 – 1.8 %) and 2.1 % (95 % CI, 1.6 – 2.6 %). After an average postoperative follow up of 19 months, the rate of tumor recurrence was 0.04 % (95 % CI, 0.01 – 0.31) among those with R0 resection and 3.6 % (95 % CI, 1.4 – 8.8 %) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 1.0 % (95 % CI, 0.42 – 2.1 %). Conclusions: Our meta-analysis, the largest and most comprehensive assessment of colorectal ESD to date, showed that colorectal ESD is safe and effective for colorectal tumors and warrants consideration as first-line therapy when an expert operator is available.

Outcomes of ulcerative colitis‐associated dysplasia patients referred for potential endoscopic submucosal dissection

“…Three recent studies on ESD for UC‐associated dysplasia have reported en bloc resection rates of 80–100% and R0 resection rates of 70–76% . These results are comparable with the outcomes summarized in the systematic reviews of ESD for almost exclusively sporadic CRN ( en bloc resection rates of 89–92% and R0 resection rates of 76–83%) . However, the R0 resection rate for ESD of UC‐associated dysplasia seems relatively lower than the pooled R0 resection rate of 85.6% reported previously in an Asian subgroup .…”

Feasibility of colorectal endoscopic submucosal dissection (ESD) carried out by endoscopists with no or little experience in gastric ESD

“…This means that it takes a longer time for Western endoscopists to obtain sufficient experience in gastric ESD, making it difficult to step up to colorectal ESD. In fact, the en bloc and R0 resection rates in Western countries were reported to be lower than in Japan; and many reports were limited to treatments of the rectum or distal colon . The aforementioned studies, particularly those from Japan, were retrospective analyses of the experience of endoscopists who have stepped up to colorectal ESD after gaining sufficient experience in gastric ESD .…”

Colorectal endoscopic submucosal dissection: patient selection and special considerations

“…However, almost all of these results are obtained from large series from expert centers in Asia, primarily Japan 9. The adoption of ESD in western practice has been very limited because of its technical difficulty, steep learning curve and the difference in training opportunities compared to Japan because of the relative scarcity of early gastric and esophageal cancer 12–14.…”

“…A multicenter study found that, regardless of the technique employed, piecemeal resection was the most important risk factor for recurrence; also, a meta-analysis of risk factors for local recurrence found that piecemeal resection was the only independent risk factor for recurrence 30,31. Akintoye et al included several thousands of cases of ESD in a meta-analysis and found a pooled recurrence rate of only 1% 9. Other meta-analyses have consistently demonstrated rates of local recurrence after ESD of 0.7%–1.2%, compared to 10.4%–12.7% after EMR 6,8,22,23…”

“…First, the risk appears to significantly reduce with experience, with one series demonstrating a reduction in perforations from 12% in its first 100 cases to 2% in the subsequent 100 cases 51. Large series of colorectal ESD suggest that the perforation rate in the hands of experienced practitioners is now in the range of 3.1%–5.6% 9–11,52–57. Second, despite an apparently higher perforation rate, the overwhelming majority of cases are recognized immediately and successfully managed by closing the defect with endoscopic clips or with conservative management and only a small fraction require surgery 10,11,52,53.…”