Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe

Abstract

Background and study aims Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results Median size was 4 cm (range 1 – 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 – 588) and median proficiency was 7.2 cm 2 /h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 – 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm 2 /h) and the last study period (10.8 cm 2 /h). Conclusions This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.

Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy

“…Thirteen studies described trainees who started colorectal ESD with previous upper gastrointestinal (UGI) ESD experience . Twelve studies described trainees with previous experience on animal models . Inada et al .…”

“…Thirteen studies described trainees who started colorectal ESD with previous upper gastrointestinal (UGI) ESD experience [29][30][31][32][33][34][35][36][37][38][39][40][41]. Twelve studies described trainees with previous experience on animal models [22,23,[25][26][27][42][43][44][45][46][47][48]. Inada et al [49] described outcomes for a trainee with previous colorectal ESD experience but fewer than 50 procedures, and one of the trainees described by Yamamoto et al [48] had experience of 20 cases of rectal ESD.…”

“…Most studies achieved an en bloc resection rate of over 80% and an R0 resection rate of over 70% at a range of 20-40 colorectal cases. Two studies reported achieving the same outcome after more than 50 or 120 cases, but the trainees in these studies were reported to have the least previous experience of performing ESD [42,47]. However, the trainees underwent training in Japan and attended hands-on animal ESD courses before starting colorectal ESD, which is the recommendation of the European Society of Gastrointestinal Endoscopy (ESGE) [51].…”

“…Two studies used other measures such as 'plateauing of procedure speed' or 'decrease in perforation rates' to determine the cut-off criteria [43,49]. Three studies used a benchmark of 6.7 min/cm 2 (> 9 cm 2 /h), suggested by Oyama et al to be adequate for proficiency in ESD [40,45,47,52]. Table 6 summarizes the studies that include data on procedural speed.…”

“…Inada et al [49] also reported slower resection in the first 100 cases despite previous ESD exposure but were describing rates in a 'difficult' group, which could explain the slower resection in that cohort. The benchmark proficiency of 6.7 min/cm 2 was achieved at 76 or 120 colorectal cases [40,47]. Zhang et al [45] reported the achievement of benchmark proficiency after 250 cases but included both UGI and LGI ESD and did not report procedural speed on colorectal cases alone.…”