Warning for unprincipled colorectal endoscopic submucosal dissection: Accurate diagnosis and reasonable treatment strategy

Abstract

Piecemeal endoscopic mucosal resection (EMR) is generally indicated for laterally spreading tumors (LST) >2 cm in diameter. However, the segmentation of adenomatous parts does not affect the histopathological diagnosis and completeness of cure. Thus, possible indications for piecemeal EMR are both adenomatous homogenous-type granular-type LST (LST-G) and LST-G as carcinoma in adenoma without segmentalizing the carcinomatous part. Diagnosis of the pit pattern using magnifying endoscopy is essential for determining the correct treatment and setting segmentation borders. In contrast, endoscopic submucosal dissection (ESD) is indicated for lesions requiring endoscopic en bloc excision, as it is difficult to use the snare technique for en bloc excisions such as in non-granular-type LST (LST-NG), especially for the pseudodepressed type, tumors with a type VI pit pattern, shallow invasive submucosal carcinoma, largedepressed tumors and large elevated lesions, which are often malignant (e.g. nodular mixed-type LST-G). Other lesions, such as intramucosal tumor accompanied by submucosal fibrosis, induced by biopsy or peristalsis of the lesion; sporadic localized tumors that occur due to chronic inflammation, including ulcerative colitis; and local residual early carcinoma after endoscopic treatment, are also indications for ESD. In clinical practice, an efficient endoscopic treatment with segregation of ESD from piecemeal EMR should be carried out after a comprehensive evaluation of the completeness of cure, safety, clinical simplicity, and cost–benefit, based on an accurate preoperative diagnosis.

Untutored Learning Curve to Establish Endoscopic Submucosal Dissection on Competence Level

“…Perforations were immediately closed by clipping and treated with intravenous antibiotics, parenteral nutrition, and in-hospital follow-up for several days after surgery [5,16,26,27]. In the ESD resection bed, any coagulated perforating arteries were clipped for prevention of bleeding.…”

“…This en-bloc resection technique is superior to Western standard techniques based on snaring, as flat neoplasms >2 cm usually require snaring in piecemeal fashion [2,5]. By contrast, ESD en-bloc allows precise tumor staging and grading and, when curative, avoids major surgery as well as recurrence [2,5,6] - strong reasons to offer ESD also to Western patients.…”

Evidence-based clinical practice guidelines for management of colorectal polyps

“…Although the local recurrence rate associated with piecemeal resection is high compared with that after en bloc resection [31,32,[47][48][49][50][51][52], most local recurrent lesions are adenomas. Cure is possible with additional endoscopic treatment for local recurrent intramucosal lesions [47,49,52,53]. In contrast, ESD allows complete en bloc resection regardless of lesion size.…”

Clinical impact of dual red imaging in colorectal endoscopic submucosal dissection: a pilot study

“…Endoscopic submucosal dissection (ESD) has been a reliable method for en-bloc resection of colorectal tumors regardless of lesion size [Tanaka et al 2007[Tanaka et al , 2008[Tanaka et al , 2012[Tanaka et al , 2013Tamegai et al 2007;Saito et al 2010;Oka et al 2010Oka et al , 2015aOka et al , 2015bTerasaki et al 2014;Ninomiya et al 2015]. Although colorectal ESD has been established as a procedure with reproducible safety and efficacy, complications such as bleeding and perforation remain problematic.…”