The efficacy of the pocket-creation method for cases with severe fibrosis in colorectal endoscopic submucosal dissection

Abstract

Background and study aims Severe fibrosis poses a challenge in colorectal endoscopic submucosal dissection (ESD). Recently, the pocket-creation method (PCM) has been developed for overcoming various difficulties of ESD. A specific tapered hood is used for adequate traction in the PCM, and endoscopic operability becomes stable in the pocket. In this study, we investigated the efficacy of the PCM in ESD for cases with severe fibrosis.

Patients and methods We retrospectively reviewed 1000 consecutive colorectal ESD cases (April 2006 to January 2017). Since 2016, the PCM was performed in 58 cases. The indications for ESD included (1) tumors ≥ 20 mm in size diagnosed as intramucosal cancer or high-grade dysplasia and part of T1a cancer using magnifying endoscopic examinations and (2) tumors that appeared impossible to resect with endoscopic mucosal resection because of suspected fibrosis. We identified 120 cases with severe fibrosis and compared them to cases without severe fibrosis. Additionally, the 120 severe fibrosis cases were divided into the PCM and non-PCM groups. En bloc resection, procedure time, discontinuation, and complications were analyzed between these 2 groups.

Results Among all 1000 ESDs, severe fibrosis and discontinuation rates were 12.0 % (120 cases) and 1.8 % (18 cases), respectively. Regarding the comparison between cases with severe fibrosis and with no severe fibrosis, there were significant differences about en bloc resection rate (78.3 % vs. 95.7 %, P < 0.001), discontinuance rate (12.5 % vs. 0.3 %, P < 0.001), and perforation rate (8.3 % vs. 2.6 %, P = 0.001). Among the 120 cases with severe fibrosis, 21 and 99 cases were in the PCM and non-PCM groups, respectively. The PCM group had a higher en bloc resection rate (95.2 vs. 74.7, P =  0.03), a shorter mean procedure time (min) (79.6 ± 26.5 vs. 118.8 ± 71.0, P = 0.001), and no cases of discontinuation. An analysis of the interobserver agreement for the diagnosis of severe fibrosis among the 3 endoscopists showed kappa values of > 0.6.

Conclusions In cases with severe fibrosis, the PCM with ESD improved en bloc resection rates and shortened the procedure time compared to the conventional non-PCM method. Additionally, the PCM reduced the discontinuation rate.

• References

• 1 Yamamoto H, Kawata H, Sunada K. et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003; 35: 690-694
• 2 Yamamoto K, Michida T, Nishida T. et al. Colorectal endoscopic submucosal dissection: recent technical advances for safe and successful procedures. World J Gastrointest Endosc 2015; 7: 1114-1128
• 3 Tanaka S, Oka S, Kaneko I. et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66: 100-107
• 4 Yoshizaki T, Toyonaga T, Tanaka S. et al. Feasibility and safety of endoscopic submucosal dissection for lesions involving the ileocecal valve. Endoscopy 2016; 48: 639-645
• 5 Saito Y, Uraoka T, Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
• 6 Yoshida N, Wakabayashi N, Kanemasa K. et al. Endoscopic submucosal dissection for colorectal tumors: technical difficulties and rate of perforation. Endoscopy 2009; 41: 758-761
• 7 Kim ES, Cho KB, Park KS. et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy 2011; 43: 573-578
• 8 Hayashi N, Tanaka S, Nishiyama S. et al. Predictors of incomplete resection and perforation associated with endoscopic submucosal dissection for colorectal tumors. Gastrointest Endosc 2014; 79: 427-435
• 9 Yoshida N, Fernandopulle N, Murakami T. et al. Difficult manipulation is one of the risk factors for incomplete resection in colorectal endoscopic submucosal dissection. J Gastroenterol Hepatol Res 2016; 5: 2063-2069
• 10 Hotta K, Katsuki S, Ohata K. et al. Efficacy and safety of endoscopic interventions using the short double-balloon endoscope in patients after incomplete colonoscopy. Dig Endosc 2015; 27: 95-98
• 11 Hayashi Y, Miura Y, Yamamoto H. Pocket-creation method for the safe, reliable, and efficient endoscopic submucosal dissection of colorectal lateral spreading tumors. Dig Endosc 2015; 27: 534-535
• 12 Sakamoto H, Hayashi Y, Miura Y. et al. Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type. Endosc Int Open 2017; 5: E123-E129
• 13 Sano Y, Ikematsu H, Fu KI. et al. Meshed capillary vessels by use of narrow-band imaging for differential diagnosis of small colorectal polyps. Gastrointest Endosc 2009; 69: 278-283
• 14 Kudo S, Hirota S, Nakajima T. et al. Colorectal tumours and pit pattern. J Clin Pathol 1994; 47: 880-885
• 15 Japanese Society for Cancer of the Colon and Rectum. Japanese Classification of Colorectal Carcinoma. 2nd ed. Tokyo, Japan: Kanehara; 2009
• 16 Hamilton SR, Aaltonen LA. , eds. World Health Organization Classification of Tumors. Pathology and Genetics of Tumours of the Digestive System. Lyon, France: IARC Press; 2010: 104-109
• 17 Yoshida N, Toyonaga T, Murakami T. et al. Efficacy of a novel narrow knife with water jet function for colorectal endoscopic submucosal dissection. Gastro Res Pract 2017; 2017: 5897369
• 18 Akahoshi K, Honda K, Akahane H. et al. Endoscopic submucosal dissection by using a grasping-type scissors forceps: a preliminary clinical study (with video). Gastrointest Endosc 2008; 67: 1128-1133
• 19 Yoshida N, Naito Y, Hirose R. et al. Risk of lens cloudiness during colorectal endoscopic submucosal dissection and ability of a novel lens cleaner to maintain and restore endoscopic view. Dig Endosc 2015; 27: 609-617
• 20 Yoshida N, Naito Y, Murakami T. et al. Safety and efficacy of a same-day low-volume 1 L PEG bowel preparation in colonoscopy for the elderly people and people with renal dysfunction. Dig Dis Sci 2016; 61: 3229-3235
• 21 Isomoto H, Nishiyama H, Yamaguchi N. et al. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 2009; 41: 679-683
• 22 Kim EK, Han DS, Ro Y. et al. The submucosal fibrosis: what does it mean for colorectal endoscopic submucosal dissection?. Intest Res 2016; 14: 358-364
• 23 Aslan F, Akpinar Z, Yurtlu DA. et al. Single tunneling method with endoscopic submucosal dissection for treatment of a rectal giant (18-cm) laterally spreading tumor. Endoscopy 2017; 49: E114-E116
• 24 Tsuji K, Yoshida N, Nakanishi H. et al. Recent traction methods for endoscopic submucosal dissection. World J Gastroenterol 2016; 22: 5917-5926