Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting gastrointestinal neoplasia of the colon, expanded experience and follow-up

Abstract

Background and study aims Colonic lesions may not be amenable to conventional endoscopic mucosal resection (EMR) due to previous manipulation, submucosal invasion, or lesion flatness. In 2018, we described Dissection-enabled Scaffold Assisted Resection (DeSCAR) to be safe for the endoscopic resection of non-lifting or residual colonic lesions [1] In this study, we expand our original cohort to describe our expanded experience with patients undergoing DeSCAR and assess the efficacy, safety, and feasibility of DeSCAR for endoscopic resection of non-lifting or residual colonic lesions.

Patients and methods We retrospectively reviewed 57 patients from 2015–2019 who underwent DeSCAR for colonic lesions with incomplete lifting and/or previous manipulation. Cases were reviewed for location, prior manipulation, rates of successful resection, adverse events, and endoscopic follow up to assess for residual lesions.

Results Fifty-seven lesions underwent DeSCAR. Of the patients, 51 % were female, and average patient age was 69 years. Lesions were located in the cecum (n = 16), right colon (n = 27), left colon (n = 10), and rectum (n = 4). Average lesion size was 27.7 mm. Previous manipulation occurred in 54 cases (72 % biopsy, 44 % resection attempt, 18 % intralesional tattoo). The technical success rate for resection of non-lifting lesions was 98 %. There were two delayed bleeding episodes (one required endoscopic intervention) and one small perforation (managed by endoscopic hemoclip closure). Endoscopic follow up was available in 31 patients (54 %) with no residual adenoma in 28 patients (90 % of those surveilled).

Conclusions Our expanded experience with DeSCAR demonstrates high safety, feasibility, and effectiveness for the endoscopic management of non-lifting or residual colonic lesions.

• References

• 1 Stier M, Chapman C, Kreitman A. et al. Dissection-enabled scaffold-assisted resection (DeSCAR): A novel technique for resection of residual or non-lifting GI neoplasia of the colon (with video). Gastrointest Endosc 2018; 87: 843-851
• 2 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2017; 49: 270-297
• 3 Buchner AM, Guarner-Argente C, Ginsberg GG. Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center. Gastrointest Endosc 2012; 76: 255-263
• 4 Burgess NG, Bourke MJ. Endoscopic resection of colorectal lesions: the narrowing divide between East and West. Dig Endosc 2016; 28: 296-305
• 5 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and metaanalysis. Gut 2016; 65: 806-820
• 6 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 7 Pellise M, Burgess NG, Tutticci N. et al. Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions. Gut 2017; 66: 644-653
• 8 Klein A, Bourke MJ. Advanced polypectomy and resection techniques. Gastrointest Endosc Clin N Am 2015; 25: 303-333
• 9 Moss A, Bourke MJ, Williams SJ. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1909-1918
• 10 Rex KD, Vemulapalli KC, Rex DK. Recurrence rates after EMR of large sessile serrated polyps. Gastrointest Endosc 2015; 82: 538-541
• 11 Han KS, Sohn DK, Choi DH. et al. Prolongation of the period between biopsy and EMR can influence the nonlifting sign in endoscopically resectable colorectal cancers. Gastrointest Endosc 2008; 67: 97-102
• 12 Uno Y, Munakata A. The non-lifting sign of invasive colon cancer. Gastrointest Endosc 1994; 40: 485-489
• 13 Matsuda T, Parra-Blanco A, Saito Y. et al. Assessment of likelihood of submucosal invasion in non-polypoid colorectal neoplasms. Gastrointest Endosc Clin N Am 2010; 20: 487-96
• 14 Nakadoi K, Tanaka S, Kanao H. et al. Management of T1 colorectal carcinoma with special reference to criteria for curative endoscopic resection. J Gastroenterol Hepatol 2012; 27: 1057-1062
• 15 Nascimbeni R, Burgart LJ, Nivatvongs S. et al. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 2002; 45: 200-206
• 16 Ikematsu H, Yoda Y, Matsuda T. et al. Long-term outcomes after resection for submucosal invasive colorectal cancers. Gastroenterology 2013; 144: 551-559; quiz e514
• 17 Kiriyama S, Saito Y, Yamamoto S. et al. Comparison of endoscopic submucosal dissection with laparoscopic-assisted colorectal surgery for early-stage colorectal cancer: a retrospective analysis. Endoscopy 2012; 44: 1024-1030
• 18 Kitajima K, Fujimori T, Fujii S. et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol 2004; 39: 534-543
• 19 Repici A, Hassan C, De Paula Pessoa D. et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy 2012; 44: 137-150
• 20 Saito Y, Matsuda T, Fujii T. Endoscopic submucosal dissection of nonpolypoid colorectal neoplasms. Gastrointest Endosc Clin N Am 2010; 20: 515-524
• 21 Tanaka S, Oka S, Kaneko I. et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66: 100-107
• 22 Fujiya M, Tanaka K, Dokoshi T. et al. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81: 583-595
• 23 Saito Y, Fukuzawa M, Matsuda T. et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24: 343-352
• 24 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
• 25 Currie AC, Askari A, Rao C. et al. The potential impact of local excision for T1 colonic cancer in elderly and comorbid populations: a decision analysis. Gastrointest Endosc 2016; 84: 986-994
• 26 Backes Y, Moons LM, van Bergeijk JD. et al. Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial. BMC Gastroenterol 2016; 16: 56
• 27 Okamoto K, Muguruma N, Kagemoto K. et al. Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases. Dig Endosc 2017; 29: 45-52
• 28 Bae JH, Yang DH, Lee S. et al. Optimized hybrid endoscopic submucosal dissection for colorectal tumors: a randomized controlled trial. Gastrointest Endosc 2016; 83: 584-592
• 29 Gorospe EC, Wong Kee Song LM. Hybrid endoscopic submucosal dissection in the colon: Cutting corners or trimming fat?. Gastrointest Endosc 2016; 83: 593-595
• 30 Friedland S, Banerjee S, Kochar R. et al. Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy proven cancer. Gastrointest Endosc 2014; 79: 101-107
• 31 Raju GS, Lum PJ, Ross WA. et al. Outcome of EMR as an alternative to surgery in patients with complex colon polyps. Gastrointest Endosc 2016; 84: 315-325
• 32 Friedland S, Shelton A, Kothari S. et al. Endoscopic management of nonlifting colon polyps. Diagn Ther Endosc 2013; 2013: 412936
• 33 Kim HG, Thosani N, Banerjee S. et al. Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions. Gastrointest Endosc 2015; 81: 204-213
• 34 Shafqet M, Caruso C, Diehl D. Treatment of neoplastic colonic lesions using the full-thickness resection device. VideoGIE 2019; 4: 535-538
• 35 Albrecht H, Raithel M, Braun A. et al. Endoscopic full-thickness resection (EFTR) in the lower gastrointestinal tract. Tech Coloprectol 2019; 23: 957-963
• 36 Velegraki M, Trikola A, Vasiliadis K. et al. Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: Clinical experience from two referral centers in Greece. Ann Gastroenterol 2019; 32: 482-488
• 37 Aepli P, Criblez D, Baumeler S. et al. Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): Clinical experience from two tertiary referral centers in Switzerland. United European Gastroenterol J 2018; 6: 463-470
• 38 Rajan E, Wong Kee Song L. Endoscopic full thickness resection. Gastroenterol 2018; 154: 1925-1937
• 39 Richter-Schrag H, Walker C, Thimme R. et al. Full thickness resection device (FTRD). Experience and outcome for benign neoplasms of the rectum and colon. Chirurg 2016; 87: 316-325
• 40 Meier B, Caca K, Schmidt A. Hybrid endoscopic mucosal resection and full-thickness resection: A new approach for resection of large non-lifting colorectal adenomas (with video). Surg Endosc 2017; 31: 4268-4274
• 41 Tsiamoulos ZP, Bourikas LA, Saunders BP. Endoscopic mucosal ablation: a new argon plasma coagulation/injection technique to assist complete resection of recurrent, fibrotic colon polyps (with video). Gastrointest Endosc 2012; 75: 400-404
• 42 Holmes I, Kim HG, Yang DH. et al. Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos). Gastrointest Endosc 2016; 84: 822-829
• 43 Watanabe T, Muro K, Ajioka Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol Epub 2017;
• 44 Andrawes S, Haber G. Avulsion: a novel technique to achieve complete resection of difficult colon polyps. Gastrointest Endosc 2014; 80: 167-168
• 45 Veerappan SG, Ormonde D, Yusoff IF. et al. Hot avulsion: a modification of an existing technique for management of nonlifting areas of a polyp (with video). Gastrointest Endosc 2014; 80: 884-888
• 46 Haber GB. Residual visible neoplasia: approaches to overt and occult polyp fragments. Gastrointest Endosc 2016; 84: 830-832
• 47 Miyamoto S, Muto M, Hamamoto Y. et al. A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms. Gastrointest Endosc 2002; 55: 576-581
• 48 Moss A, Bourke MJ, Tran K. et al. Lesion isolation by circumferential submucosal incision prior to endoscopic mucosal resection (CSI-EMR) substantially improves en bloc resection rates for 40-mm colonic lesions. Endoscopy 2010; 42: 400-404
• 49 Sakamoto T, Matsuda T, Nakajima T. et al. Efficacy of endoscopic mucosal resection with circumferential incision for patients with large colorectal tumors. Clin Gastroenterol Hepatol 2012; 10: 22-26
• 50 Sold M, Kähler G. Improved techniques for endoscopic mucosal resection (EMR) in colorectal adenoma. Viszeralmedizin 2014; 30: 33-38
• 51 Dauser B, Winkler T, Salehi B. et al. Traction-assisted endoscopic mucosal resection for polypectomy in the large intestine. World J Gastroenterol 2010; 16: 5462-5466
• 52 Lee EJ, Lee JB, Lee SH. et al. Endoscopic treatment of large colorectal tumors: comparison of endoscopic mucosal resection, endoscopic mucosal resection-precutting, and endoscopic submucosal dissection. Surg Endosc 2012; 26: 2220-2230