Subscribe to RSS
DOI: 10.1055/a-2256-6724
Endoskopische Resektionsverfahren von flächigen Präkanzerosen und Frühkarzinomen im Rektum
Endoscopic Resection Techniques for Precancerous and Early Cancerous Lesions in the Rectum
Zusammenfassung
Die Endoskopie spielt heute nicht nur in der Erkennung von kolorektalen Adenomen und Karzinomen eine entscheidende Rolle, sondern auch in der Behandlung von insbesondere flächigen Adenomen und frühen Karzinomen. In den letzten Jahren hat neben der klassischen Polypektomie und Mukosaresektion flach-erhabener Läsionen mit der Schlinge (EMR), die endoskopische Submukosadissektion (ESD) einen zunehmenden Stellenwert erlangt. Hierbei erfolgt nach Markierung, Unterspritzung und Inzision der Mukosa um die Läsion, die Untertunnelung und das „En-bloc“-Auslösen durch eine transparente Aufsatzkappe und ein feines Diathermiemesser. Gerade bei flächigen Veränderungen mit hohem Rezidivrisiko einer Piecemeal-Resektion durch EMR sowie bei Risikoläsionen ermöglicht die ESD, nahezu größenunabhängig in der Hand des Erfahrenen, einen sicheren Abtrag mit einer histologischen R0-Resektionsrate an Zentren von weit über 90%. Die ESD ermöglicht eine optimale histopathologische Ausbeute und weist ein niedriges Rezidivrisiko von 1–3% auf. Eine weitere Bereicherung des Armamentariums stellt die endoskopische Vollwandresektion mit einem speziellen Applikationssystem dar (FTRD-System). Dieses eignet sich für umschriebene submuköse, suspekte oder narbige Veränderungen bis 2 cm Größe im mittleren und oberen Rektum. Die endoskopische intermuskuläre Dissektion (EID) ermöglicht durch Mitnahme der zirkulären inneren Muskelschicht bei der Resektion die histopathologische Analyse der kompletten Submukosa über Mukosa und obere Submukosaschicht hinaus. Sie bietet bei T1-Karzinomen ein geringeres Risiko der basalen R1-Situation und eine neue Perspektive durch die kurative, organerhaltende endoskopische Therapie bei alleiniger tiefer Submukosainfiltration ohne weitere Risikofaktoren für eine Metastasierung. Indikationen, Technik und Stellenwert der verschiedenen Techniken bei prämaligen und frühmaligen Läsionen im Rektum werden dargestellt.
Abstract
Today, endoscopy plays a decisive role not only in the detection of colorectal adenomas and carcinomas, but also in the treatment of precancerous lesions, in particular flat adenomas and early carcinomas. In recent years, endoscopic submucosal dissection (ESD) has become increasingly important alongside classic polypectomy and mucosal resection after saline injection using a snare (EMR). Using ESD the lesion is marked, injected submucosally using viscous substances and the mucosa incised and tunneled with a transparent cap and a fine diathermy knife. Particularly in the case of widespread and high-risk lesions ESD enables a quasi-surgical “en bloc” resection almost regardless of size, with a histological R0 resection rate of far over 90% in specialized centers. ESD enables an excellent histopathological evaluation and has a low recurrence risk of 1–3%. Endoscopic full-thickness resection using a dedicated device (FTRD system) represents another addition to the armamentarium. It can be used for circumscribed submucosal, suspicious or scarred changes up to 2 cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) enables histopathological analysis of the complete submucosa beyond the mucosa and upper submucosal layer by including the circular inner muscle layer within the resection specimen. It reduces basal R1 situations and offers a new perspective for T1 carcinomas through curative, organ-preserving endoscopic therapy, especially in the case of deep submucosal infiltration alone, without other risk factors for metastases. Indications, the procedure itself and significance of the various techniques for premalignant and early malignant lesions in the rectum are presented.
Schlüsselwörter
Rektumkarzinom - en bloc - endoskopische intermuskuläre Dissektion (EID) - endoskopische Submukosadissektion (ESD) - T1-Rektumkarzinom - endoskopische InterventionKeywords
en bloc - rectal carcinoma/cancer - endoscopic intermuscular dissection (EID) - endoscopic submucosal dissection (ESD) - T1 rectal cancer - endoscopic interventionPublication History
Received: 06 December 2023
Accepted after revision: 23 January 2024
Article published online:
05 March 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
Literatur
- 1 Brenner H, Heisser T, Cardoso R. et al. Reduction in colorectal cancer incidence by screening endoscopy. Nat Rev Gastroenterol Hepatol 2024; 21: 125-133 DOI: 10.1038/s41575-023-00847-3. (PMID: 37794234)
- 2 Brenner H, Altenhofen L, Stock C. et al. Prevention, early detection, and overdiagnosis of colorectal cancer within 10 years of screening colonoscopy in Germany. Clin Gastroenterol Hepatol 2015; 13: 717-723 DOI: 10.1016/j.cgh.2014.08.036.
- 3 Repici A, Spadaccini M, Antonelli G. et al. Artificial intelligence and colonoscopy experience: lessons from two randomised trials. Gut 2022; 71: 757-765 DOI: 10.1136/gutjnl-2021-324471.
- 4 Rath T. Missed lesions and artificial intelligence during colonoscopy: the tireless working expert in the room. Endoscopy 2022; 54: 473-474 DOI: 10.1055/a-1669-8814. (PMID: 34905793)
- 5 Messmann H, Bisschops R, Antonelli G. et al. Expected value of artificial intelligence in gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2022; 54: 1211-1231 DOI: 10.1055/a-1950-5694. (PMID: 36270318)
- 6 Pimentel-Nunes P, Libânio D, Bastiaansen BAJ. et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54: 591-622 DOI: 10.1055/a-1811-7025. (PMID: 35523224)
- 7 Yamada M, Saito Y, Sakamoto T. et al. Endoscopic predictors of deep submucosal invasion in colorectal laterally spreading tumors. Endoscopy 2016; 48: 456-464 DOI: 10.1055/s-0042-100453. (PMID: 26919264)
- 8 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc [Anonym]. 2003; 58(6 Suppl): S3-S43 DOI: 10.1016/s0016-5107(03)02159-x.
- 9 Lambert R. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578 DOI: 10.1055/s-2005-861352.
- 10 Tanaka S, Kashida H, Saito Y. et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2020; 32: 219-239 DOI: 10.1111/den.13545. (PMID: 31566804)
- 11 Burgess NG, Hourigan LF, Zanati SA. et al. Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. Gastroenterology 2017; 153: 732-742.e1 DOI: 10.1053/j.gastro.2017.05.047.
- 12 Sun LY. [Essential and interpretation of Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer]. Zhonghua Wei Chang Wai Ke Za Zhi 2019; 22: 1088-1094 DOI: 10.3760/cma.j.issn.1671-0274.2019.11.016. (PMID: 31770843)
- 13 Sano Y, Tanaka S, Kudo SE. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533 DOI: 10.1111/den.12644. (PMID: 26927367)
- 14 Huang SL, Tan WX, Peng Q. et al. Blue laser imaging combined with JNET (Japan NBI Expert Team) classification for pathological prediction of colorectal laterally spreading tumors. Surg Endosc 2021; 35: 5430-5440 DOI: 10.1007/s00464-020-08027-z.
- 15 Hochberger J, Koehler P, Wedi E. et al. Endoscopic Mucosal Resection, Submucosal Dissection, and Full Thickness Resection Techniques. In: Cohen J. Successful Training in Gastrointestinal Endoscopy. Oxford: Wiley-Blackwell; 2022: 233-272 DOI: 10.1002/9781119529675
- 16 Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF. S3-Leitlinie Kolorektales Karzinom. Version 2.1. 2019. AWMF-Registernummer: 021/007OL. Accessed February 05, 2024 at: https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Kolorektales_Karzinom/Version_2/LL_KRK_Langversion_2.1.pdf
- 17 Glynne-Jones R, Wyrwicz L, Tiret E. et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28: iv22-iv40 DOI: 10.1093/annonc/mdx224. (PMID: 28881920)
- 18 Detering R, van Oostendorp SE, Meyer VM. et al. MRI cT1–2 rectal cancer staging accuracy: a population-based study. Br J Surg 2020; 107: 1372-1382 DOI: 10.1002/bjs.11590. (PMID: 32297326)
- 19 Deyhle P, Jenny S, Fumagalli I. [Endoscopic polypectomy in the proximal colon. A diagnostic, therapeutic (and preventive?) intervention]. Dtsch Med Wochenschr 1973; 98: 219-220 DOI: 10.1055/s-0028-1106782. (PMID: 4684531)
- 20 Tate DJ, Sidhu M, Bar-Yishay I. et al. Impact of en bloc resection on long-term outcomes after endoscopic mucosal resection: a matched cohort study. Gastrointest Endosc 2020; 91: 1155-1163.e1 DOI: 10.1016/j.gie.2019.12.025.
- 21 Bourke MJ, Bhandari P. How I remove polyps larger than 20 mm. Gastrointest Endosc 2019; 90: 877-880 DOI: 10.1016/j.gie.2019.08.031.
- 22 Sidhu M, Shahidi N, Gupta S. et al. Outcomes of Thermal Ablation of the Mucosal Defect Margin After Endoscopic Mucosal Resection: A Prospective, International, Multicenter Trial of 1000 Large Nonpedunculated Colorectal Polyps. Gastroenterology 2021; 161: 163-170.e3 DOI: 10.1053/j.gastro.2021.03.044.
- 23 Hochberger J, Biesecker K. Endoskopische Submucosa Dissektion. In: Gottschalk U, Maeting S, Kahl S. Arbeitsplatzbuch Endoskopie. Stuttgart: Thieme; 2019: 233-242
- 24 Hochberger J, Meves V. Endoskopische Submucosa-Dissektion. In: Riemann JF, Fischbach W, Galle PR, Mössner J. Referenz Gastroenterologie. Stuttgart: Thieme; 2019: 1010-1018
- 25 Libânio D, Pimentel-Nunes P, Bastiaansen B. et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55: 361-389 DOI: 10.1055/a-2031-0874. (PMID: 36882090)
- 26 Yamashina T, Nemoto D, Hayashi Y. et al. Prospective randomized trial comparing the pocket-creation method and conventional method of colorectal endoscopic submucosal dissection. Gastrointest Endosc 2020; 92: 368-379 DOI: 10.1016/j.gie.2020.02.034. (PMID: 32119937)
- 27 Moons LMG, Bastiaansen BAJ, Richir MC. et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54: 993-998 DOI: 10.1055/a-1748-8573. (PMID: 35073588)
- 28 Pimentel-Nunes P, Pioche M, Albeniz E. et al. Curriculum for endoscopic submucosal dissection training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2019; 51: 980-992 DOI: 10.1055/a-0996-0912. (PMID: 31470448)
- 29 Fleischmann C, Probst A, Ebigbo A. et al. Endoscopic Submucosal Dissection in Europe: Results of 1000 Neoplastic Lesions From the German Endoscopic Submucosal Dissection Registry. Gastroenterology 2021; 161: 1168-1178 DOI: 10.1053/j.gastro.2021.06.049.
- 30 Tribonias G, Komeda Y, Leontidis N. et al. Endoscopic intermuscular dissection (EID) for removing early rectal cancers and benign fibrotic rectal lesions. Tech Coloproctol 2023; 27: 1393-1400 DOI: 10.1007/s10151-023-02862-7. (PMID: 37773471)
- 31 Marin FS, Abou Ali E, Belle A. et al. "Transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM): a new endoscopic treatment for suspicious deep submucosal invasion T1 rectal carcinoma. Surg Endosc 2023; 37: 5714-5718 DOI: 10.1007/s00464-023-10141-7.
- 32 Ichita C, Sasaki A, Kawachi J. et al. Endoscopic intermuscular dissection for a lower rectal gastrointestinal stromal tumor. Endoscopy 2023; 55: E258-E259 DOI: 10.1055/a-1974-8823. (PMID: 36427499)
- 33 Longcroft-Wheaton G. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum. Is this the dawn of the endoscopic cancer surgeon?. Endoscopy 2022; 54: 999-1000 DOI: 10.1055/a-1835-2403. (PMID: 35613921)
- 34 Toyonaga T, Ohara Y, Baba S. et al. Peranal endoscopic myectomy (PAEM) for rectal lesions with severe fibrosis and exhibiting the muscle-retracting sign. Endoscopy 2018; 50: 813-817 DOI: 10.1055/a-0602-3905.
- 35 Watanabe D, Toyonaga T, Ooi M. et al. Clinical outcomes of deep invasive submucosal colorectal cancer after ESD. Surg Endosc 2018; 32: 2123-2130 DOI: 10.1007/s00464-017-5910-5. (PMID: 29098429)
- 36 Yamada M, Saito Y, Takamaru H. et al. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017; 49: 233-242 DOI: 10.1055/s-0042-124366. (PMID: 28107766)
- 37 Eid Y, Alves A, Lubrano J. et al. Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature. J Visc Surg 2018; 155: 445-452 DOI: 10.1016/j.jviscsurg.2018.03.008.
- 38 Hompes R, McDonald R, Buskens C. et al. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Colorectal Dis 2013; 15: e576-e581 DOI: 10.1111/codi.12381. (PMID: 24635913)
- 39 Emiloju OE, Sinicrope FA. Neoadjuvant Immune Checkpoint Inhibitor Therapy for Localized Deficient Mismatch Repair Colorectal Cancer: A Review. JAMA Oncol 2023; 9: 1708-1715 DOI: 10.1001/jamaoncol.2023.3323. (PMID: 37676680)
- 40 Ludford K, Ho WJ, Thomas JV. et al. Neoadjuvant Pembrolizumab in Localized Microsatellite Instability High/Deficient Mismatch Repair Solid Tumors. J Clin Oncol 2023; 41: 2181-2190 DOI: 10.1200/jco.22.01351. (PMID: 36623241)
- 41 Pox C. Checkpointinhibitoren beim kolorektalen Karzinom – eine neue Ära?. Inn Med (Heidelb) 2023; 64: 500-505 DOI: 10.1007/s00108-023-01495-0.
- 42 Schiemer M, Schmidt A. [Current endoscopic resection techniques in the colorectum: possibilities, perspectives, limitations]. Dtsch Med Wochenschr 2023; 148: 84-93 DOI: 10.1055/a-1832-4090. (PMID: 36690004)
- 43 Kuellmer A, Mueller J, Caca K. et al. Endoscopic full-thickness resection for early colorectal cancer. Gastrointest Endosc 2019; 89: 1180-1189.e1 DOI: 10.1016/j.gie.2018.12.025.
- 44 Zwager LW, Bastiaansen BAJ, Montazeri NSM. et al. Deep Submucosal Invasion Is Not an Independent Risk Factor for Lymph Node Metastasis in T1 Colorectal Cancer: A Meta-Analysis. Gastroenterology 2022; 163: 174-189 DOI: 10.1053/j.gastro.2022.04.010. (PMID: 35436498)
- 45 Bosch SL, Teerenstra S, de Wilt JH. et al. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions. Endoscopy 2013; 45: 827-834 DOI: 10.1055/s-0033-1344238. (PMID: 23884793)
- 46 Chen Y, Jing W, Chen M. et al. Long-term outcomes of local resection versus surgical resection for high-risk T1 colorectal cancer: a systematic review and meta-analysis. Gastrointest Endosc 2023; 97: 1016-1030.e14 DOI: 10.1016/j.gie.2023.02.027.
- 47 Bentrem DJ, Okabe S, Wong WD. et al. T1 adenocarcinoma of the rectum: transanal excision or radical surgery?. Ann Surg 2005; 242: 472-477 DOI: 10.1097/01.sla.0000183355.94322.db. (PMID: 16192807)
- 48 Tejedor P, Arredondo J, Pellino G. et al. Patient Reported Outcomes following Cancer of the Rectum (PROCaRe): protocol of a prospective multicentre international study. Tech Coloproctol 2023; 27: 1345-1350 DOI: 10.1007/s10151-023-02865-4. (PMID: 37770748)
- 49 Machackova M, Skrovina M, Szikhart M. et al. Urogenital dysfunction in patients after miniinvasive restorative low anterior resection with total mesorectal excision. Wideochir Inne Tech Maloinwazyjne 2022; 17: 506-514 DOI: 10.5114/wiitm.2022.116394.
- 50 van der Valk MJM, van der Sande ME, Toebes RE. et al. Importance of patient reported and clinical outcomes for patients with locally advanced rectal cancer and their treating physicians. Do clinicians know what patients want?. Eur J Surg Oncol 2020; 46: 1634-1641 DOI: 10.1016/j.ejso.2020.04.014.
- 51 Corre F, Albouys J, Tran VT. et al. Impact of surgery after endoscopically resected high-risk T1 colorectal cancer: results of an emulated target trial. Gastrointest Endosc 2023; DOI: 10.1016/j.gie.2023.09.027. (PMID: 37793506)
- 52 Takamaru H, Saito Y, Sekiguchi M. et al. Endoscopic Resection Before Surgery Does Not Affect the Recurrence Rate in Patients With High-Risk T1 Colorectal Cancer. Clin Transl Gastroenterol 2021; 12: e00336 DOI: 10.14309/ctg.0000000000000336.
- 53 Tate DJ, Argenziano ME, Anderson J. et al. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023; 55: 645-679 DOI: 10.1055/a-2077-0497. (PMID: 37285908)