Hybrid endoscopic submucosal dissection: An alternative resection modality for large laterally spreading tumors in the cecum?

Abstract

Background Endoscopic resection for large, laterally spreading tumors (LSTs) in the cecum is challenging. Here we report on the clinical outcomes of hybrid endoscopic submucosal dissection (ESD) in large cecal LSTs. Methods We retrospectively reviewed data from patients with cecal LSTs ≥ 2 cm who underwent ESD or hybrid ESD procedures between January of 2008 and June of 2019. We compared the baseline characteristics and clinical outcomes, including procedure time, the en bloc and complete resection rates, and adverse events. Results A total of 62 patients were enrolled in the study. There were 27 patients in the ESD group and 35 patients in the hybrid ESD group, respectively. Hybrid ESD was more used for lesions with submucosal fibrosis. No other significant differences were found in patient characteristics between the two groups. The hybrid ESD group had a significantly shorter procedure time compared with the ESD group (27.60 ± 17.21 vs. 52.63 ± 44.202 min, P = 0.001). The en bloc resection rate (77.1% vs. 81.5%, P = 0.677) and complete resection rate (71.4% vs. 81.5%, P = 0.359) of hybrid ESD were relatively lower than that of the ESD group in despite of no significant difference was found. The perforation and post-procedure bleeding rate (2.9% vs. 3.7%, P = 0.684) were similar between the two groups. One patient perforated during the ESD procedure, which was surgically treated. One patient in the hybrid ESD group experienced post-procedure bleeding, which was successfully treated with endoscopic hemostasis. Post-procedural fever and abdominal pain occurred in six patients in the ESD group and five patients in the hybrid ESD group. One patient in the ESD group experienced recurrence, which was endoscopically resected. Conclusion The results of this study indicate that hybrid ESD may be an alternative resection strategy for large cecal LSTs with submucosal fibrosis.

Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases

“…Previous reports on the clinical outcomes of hybrid ESD and C-ESD for colorectal lesions are summarized in Table 4. 11,17,[19][20][21][22][23][24][25][26] Although several studies have shown that the en bloc resection rate is significantly lower with the use of hybrid ESD techniques (56.8%-94.1%) than with the use of C-ESD techniques (81.5%-100%), most did not classify hybrid ESD into preplanned SH-ESD and unplanned RH-ESD. [18][19][20]22 In general, planned SH-ESD is used for relatively small tumors that can be easily snared, whereas unplanned RH-ESD is used for lesions that are difficult to resect.…”

Understanding hybrid endoscopic submucosal dissection subtleties

“…However, the limited data on H-ESD renders its com- parison with conventional ESD (C-ESD) difficult (Fig. 6 Hybrid endoscopic resections can be perfomed in different ways. Specific terminologies have been previously described and must be used to distinguish the various forms of this approach.…”

“…Capturing a too large portion of submucosa may deform attached layers, leading to unplanned cutting levels with a higher risk of damage to the muscularis propria or fragmentation of the lesion. 6 When faced with difficult situations, such as severe fibrosis, prolonged procedure time, large perforations, massive bleeding, and unstable vital signs, endoscopists should be ready to shift from the C-ESD to RH-ESD for faster resolution of the procedure. Prolonged or complicated endoscopic procedures can influence the physician's decision-making process and focus and have a higher physiological impact on the patient.…”

“…Notwithstanding the advantages, proper indication and timing have yet to be established. 6,7 From a practical standpoint, RH-ESD can be used to safely avoid surgical intervention, with a lower en bloc rate than that of the conventional technique. The reported 4.2% recurrence rate can be managed by additional EMR or thermal avulsion.…”

Endoscopic Resection of Gastrointestinal Lesions: Preference and Feasibility of En bloc Resection Techniques

“…Then, the remaining lesion is completely resected with a snare. 56 A study on small (≤20 mm) early gastric neoplasms revealed that the hybrid technique has a shorter procedure time (33 minutes vs. 62 min-utes), with comparable curability and safety, when compared to ESD (possible lower thermal damage to the submucosal layer in H-ESD). 57 A shorter procedure time was observed for H-ESD, when compared to conventional ESD, for colonic lesions, with a lower en bloc and R0 resection rate.…”