ISSN: 2373-6372GHOA

Gastroenterology & Hepatology: Open Access
Research Article
Volume 4 Issue 5 - 2016
Modified Endoscopic Submucosal Dissection Technique to Achieve En Bloc Resection of Giant (≥3 Cm) Subpedunculated (Stalk<1 Cm) Colorectal Tumors
Hong Shi*, Su-Yu Chen, Zhao-Fei Xie, Jian-Yun Huang and Yan Jiang
Department of Gastrointestinal Endoscopy, Teaching Hospital of Fujian Medical University, China
Received: April 19, 2016 | Published: May 06, 2016
*Corresponding author: Hong Shi, Department of Gastrointestinal Endoscopy, Fujian Provincial Tumor Hospital, Teaching Hospital of Fujian Medical University, No 420 Fu Ma Road, Fuzhou 350014, Fujian, China, Email:
Citation: Shi H, Chen SY, Xie ZF, Huang JY, Jiang Y (2016) Modified Endoscopic Submucosal Dissection Technique to Achieve En Bloc Resection of Giant (≥3 Cm) Subpedunculated (Stalk<1 Cm) Colorectal Tumors. Gastroenterol Hepatol Open Access 4(5): 00114. DOI: 10.15406/ghoa.2016.04.00114

Introduction

Colonoscopic polypectomy has become a standard method of treatment for colorectal polypoidlesions since introduced in the early 1970s [1]. However, the risks of complications, such as bleeding, perforation, piecemeal and incomplete resection increases with giant, subpedunculated tumors, especially those located at folds and flexures. Given that the size of the polyp is an important risk factor for malignancy and its invasiveness, a piecemeal resection may lead to inaccurate histo-pathologic assessment and subsequent inadequate decision making [2].

ESD (endoscopic submucosal dissection) is an effective alternative to achieve en bloc resection in difficult cases, such as giant (at least 3cm in diameter.) and subpedunculated (stalk shorter than 1 cm) neoplastic lesions because the procedure is performed under direct visualization of the submucosal layer, allowing precise hemostasis. Meanwhile, colorectal ESD is technically demanding because inherited anatomic variability in the colon such as flexures, folds, or looping in mobile segments of the colon attached to the mesentery may hinder endoscopic stable intervention [3]. In our study, ESD using retroflex-view technique was used to remove giant subpedunculated colorectal polyps to evaluate its feasibility and safety.

Patients and Methods

Patients

Between January2015 and January2016, 36 patients with 37 giant (3 cm or larger) subpedunculated (Short stalked) colorectal tumors were enrolled consecutively, and informed written consent was obtained from all patients before ESD.

ESD procedure

Under general anesthesia with endotracheal intubation, modified ESD was performed with carbon dioxide insufflation, using a single-channel gastrointestinal endoscope with a transparent attachment hood fitted to the tip (PCF-Q260JI; GIF-Q260J; Olympus). An ICC 200 electrosurgical generator (ERBE Elektromediz in, Tubingen, Germany) was set to the Endo-Cut mode (Effect 3, 80 W) for incision of the mucosa, and to the Endo-Cut mode (Effect 3, 80 W) or forced coagulation mode (35 W) for dissection of the submucosa. Hemorrhage was controlled using Coagrasper (FD-411 LR; Olympus) in the soft coagulation mode (80 W).

Once successful retroflexion of endoscope was achieved, the proximal side of the tumor was precut and dissected with Dual knife (KD-650Q; Olympus) after a submucosal injection with a mixed solution glycerol and hyaluronic acid (Figure 1 & 2). Then in the forward view, a circumferential mucosal incision was completed around the base of the polyp stalk, and the dissection of the submucosal layer, with Dual knife or IT knife, was performed. When large vessels were encountered, a Coagrasper or a scissor-type grasping knife (SB knife Jr, Sumitomo Bakelite) was used to coagulate and cut vessels (Figure 3 & 4). After complete dissection, the visible vessels in the exposed layer were treated with a Coagrasper in a soft coagulation mode. Finally, each post-ESD mucosal defect was completely closed with hemoclips (Figure 5 & 6).

Figure 1: Retroflexed view at the sigmoid colon.
Figure 2: Oral side precut with a retroflexed view at the sigmoid colon.
Figure 3: Large vessel with a forward view at the sigmoid colon.
Figure 4: Endoscopic view after vessel cutting using SB knife.
Figure 5: Endoscopic view of post-ESD defect.
Figure 6: Closure of post-ESD defect with clips.

In case of retroflexion failure, the distal one-third of the mucosa, around the base of the stalk, was incised first, as illustrated by Choi YS [2]. All procedures were performed in an inpatient setting, and the patients underwent a 24-hour fasting period, then were discharged 48 hours after the ESD procedure. After R0 resection was confirmed, patients received a follow-up endoscopic surveillance, at 3, 6 and 12 months, and annually, thereafter.

Results

Characteristics of the lesions

A total of 36 patients (37 giant subpedunculated tumors) with a mean tumor size of 36.7 mm undergoing modified colorectal ESD were enrolled in the study. The tumor clinico-pathological features are summarized in Table 1. The detailed characteristics including the tumor size, the tumor distribution and the procedure times in our study were comparable with the report of Choi YS [2].

 

Our study (n=37)

Choi YS [2] (n=23)

Size of tumor, mean ± SD, mm

36.7±5.1mm

36.8±4.6mm

Location

 

 

Left-sided

31/37(83.8%)

18/23(78.3%)

Procedure time, mean ± SD (range), min

31.8±29.3min

44.9±35.6min

en bloc resection, n (%)

37/37 (100%)

23/23(100%)

R0 resection, n (%)

37/37 (100%)

23/23(100%)

Procedure-related complication, n (%)

 

 

Bleeding

0

1/23 (4.3)

Perforation

0

0

Pathology, n (%)

 

 

High-grade intraepithieal neoplasia

37/37 (100%)

19/23(82.6%)

Carcinoma

 

4/23(17.4%)

Table 1:Clinicopathologic features of colorectal tumors and outcomes of ESD.

Outcome of modified colorectal ESD

The successful rate of retroflexion was 89.2% (33/37). Both en bloc resection rate and the R0 resection rate were 100% (37/37) in our study. There were no immediate or delayed adverse events (eg, bleeding, perforation) in any of the 36 patients.

Discussion

The value of retroflexion in the right, transverse colon, or the rectum to facilitate removal of difficult-to-access colorectal tumors has been well described [4]. Retroflexion was able to counter the respiratory interference and stabilized the visual field, allowing to shorten the procedure time. Caution should be exercised in performing retroflexion in the descending and sigmoid colon, which may result in colonic perforation. Moreover, it was difficult to achieve retroflexion in the sigmoid colon due to a loop or the narrowness of the lumen.

Besides the classical ESD proposed by Choi YS [2], there are some analogous techniques designed for the resection of giant subpedunculated/pedunculated colorectal tumors which are judged to be difficult to perform polypectomy by snaring their stalks. Among them, scissor-type forceps with a strong curve are used to cut a giant a giant pedunculated tumor in the sigmoid colon [5], pocket-creation method of ESD facilitates the treatment of giant, subpedunculated, neoplastic lesions with severe fibrosis at the center [6], and an insulated-tip knife can be used to cut the stalk of a giant long-stalked polyp located in the sigmoid colon [7]. The detailed characteristics were listed in Table 2.

Technical feature

Knives

Advantages

Disadvantages

Choi YS [2]

Classical ESD

Flex

Dissection under direct visualization

Kume K [5]

Endoscopic resection

SB

Without concern of perforation risk

Multiple clips placed beforehand

Hayashi Y [6]

pocket-creation method

Dual

Useful for lesions with severe fibrosis

Zhai Y [7]

Endoscopic resection

IT

Fast-acting

Not suitable for short-stalked tumors

Our study

ESD in retroflexion

Dual/IT/SB

Stable platform for ESD

Retroflexion failure

Table 2: ESD and its similar techniques used to resect giant colorectal subpedunculated neoplastic lesions.

So far, there is no consensus in the available literature regarding the need to close the post-resection gastrointestinal mucosal defects. In our experience, closure of post-ESD defects with endoscopic clips allowed us to shorten patients’ hospital stay and avoid any delayed perforations or delayed bleeding. For large mucosal defects, endoscopic suturing closure with the Overstitch endoscopic suturing device maybe more reliable due to full-thickness tissue approximation[8].

Conclusion

ESD procedure with retroflex-view is an effective and safe alternative to achieve en bloc R0 resection of giant subpedunculated colorectal tumors which are difficult to perform polypectomy.

References

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  2. Choi YS, Lee JB, Lee EJ, Lee SH, Suh JP, et al. (2013) Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥30 mm) pedunculated colorectal polyp? Dis Colon Rectum. 56(5): 660-606.
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  8. Kantsevoy SV, Bitner M, Mitrakov AA, Thuluvath PJ (2014) Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos). Gastrointest Endosc. Mar; 79(3): 503-507.
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