Prediction and Treatment of Difficult Cases in Colorectal Endoscopic Submucosal Dissection

Abstract

Purpose. The aim of this study was to examine the characteristics of difficult cases and the learning curve in colorectal endoscopic submucosal dissection (ESD). Methods. We studied 518 colorectal tumors treated by ESD. Patients were divided into 2 groups such as the difficult ESD group and non-difficult ESD group in view of procedure time and procedure speed, respectively. The clinical features in each group were analyzed, and we also examined cases with severe fibrosis. Furthermore, we divided all cases into 5 periods according to experience of ESDs and investigated the rates of difficult and perforation cases. Results. In view of both procedure time and procedure speed, there were significant differences about mean tumor size, rates of severe fibrosis and perforation, and en bloc resection rate between the two groups. Severe fibrosis was detected in protruding tumors >40 mm in diameter. With respect to the learning curve, the rate of difficult and perforation cases decreased significantly in the late periods compared to the first period. Conclusions. Large tumor size, high rates of severe fibrosis and perforation, and low rate of en bloc resection are related with difficult ESD cases. The increasing of experiences can decrease the rate of difficult cases and perforation.

Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: Pathologic review of 173 cases

“…Endoscopic submucosal dissection (ESD) is accepted as an effective treatment for early‐stage gastric cancer . In addition, this technique has been applied to colorectal tumors and has yielded positive results with an en bloc resection rate of 80∼92% . However, colorectal ESD is technically difficult due to the presence of a thin wall and tortuous folds, and it is associated with a substantial risk of complications .…”

Difficult Manipulation is One of the Risk Factors for Incomplete Resection in Colorectal Endoscopic Submucosal Dissection

“…Difficulties of ESD result in incomplete en bloc resection and perforation in colorectal ESD [6][7][8][9][10] . It is therefore important to predict difficult cases.…”

“…There are other factors attributed to this perceived difficulty. The location, size of the lesion, and degree of fibrosis has been previously identified as risk factors for incomplete resection and perforation of colorectal ESD [7][8][9][10] . Since these risk factors made ESD difficult to perform, only experts conducted the procedure in the early years.…”

“…Since these risk factors made ESD difficult to perform, only experts conducted the procedure in the early years. Recently, most of these challenges have been resolved by improving on existing devices, utilizing suitable strategies, and learning from the operators' experiences [6,9] . Thus, in many institutions where ESD is performed, the rates of en bloc resection have increased and perforation rates have decreased.…”

“…The insertion time was calculated during the colonoscopy pre-check in most cases and it was calculated on the ESD day in some cases. The procedure speed was calculated according to a previously reported method [9] by dividing the procedure time by the area of the resected specimen (cm 2 /min). Briefly, the area of resected specimen was calculated as follows: 3.14 × 0.25 × long axis x minor axis.…”