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Endoscopy 2010; 42(10): 806-813
DOI: 10.1055/s-0030-1255715
Original article

© Georg Thieme Verlag KG Stuttgart · New York

A national survey of endoscopic mucosal resection for superficial gastrointestinal neoplasia

D.  Heresbach1 , R.  Kornhauser1 , J.  A.  Seyrig1 , D.  Coumaros1 , C.  Claviere1 , A.  Bury1 , J.  Cottereau1 , J.  M.  Canard1 , S.  Chaussade1 , A.  Baudet1 , A.  Casteur1 , O.  Duval1 , T.  Ponchon1, of the OMEGA group
  • 1Observatoire de la Mucosectomie Endoscopique en Gastroenterologie (OMEGA), under the aegis of the Société Française d’Endoscopie Digestive (SFED), Paris, France
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Publication History

submitted 14 December 2009

accepted after revision 14 June 2010

Publication Date:
06 September 2010 (online)

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Commentaire de travail de D. Heresbach et al., pp. 806Endoscopy 2010; 42(10): 883-883
DOI: 10.1055/s-0032-1306718

Background and study aim: Studies on endoscopic mucosal resection (EMR) are mostly based on data from centers with high expertise. We report the average EMR results in a national survey of consecutive patients in France.

Methods: A 1-year survey was carried out to record immediate outcome data of all EMRs performed, regardless of lesion size or gastrointestinal location.

Results: Overall, 1335 EMRs in 1210 patients were reported by 241 of the 736 gastroenterologists who performed such procedures (33 %). Resections were done for upper gastrointestinal lesions in 125 cases (41 esophageal, 43 gastric, and 41 duodenal lesions), in 45 % of cases using specific EMR techniques such as ligation, cap, or traction. The technique for resecting the 1210 lower gastrointestinal lesions mostly consisted of saline-assisted polypectomy or EMR, with specific techniques used in only 2.2 %. En bloc resection was less common with esophageal (46 %) or duodenal (54 %) neoplasms than in the lower gastrointestinal tract (73 %); size also had some influence (53 % > 1 cm vs. 92 % ≤ 1 cm). The overall complication rate was 5.2 %; the rate was lower for lesions 1 cm or smaller (0.6 % vs. 4.6 %). Fifty-four early and 17 delayed complications were recorded, in 12 % of upper gastrointestinal and 4.6 % of colonic lesions. Surgery became necessary in 1.6 % for upper and 2.9 % for lower gastrointestinal neoplasms. No association was seen between physician EMR caseload and either en bloc resection rate or complication rate.

Conclusions: EMR in general, especially saline-assisted polypectomy in the colon, appears to be reasonably safe even when performed by nonexperts. EMR for larger or for upper gastrointestinal lesions should probably be limited to high-volume centers.

References

  • 1 Larghi A, Waxman I. State of the art on endoscopic mucosal resection and endoscopic submucosal dissection.  Gastrointest Endosc Clin N Am. 2007;  17 441-469
    CrossrefPubMedSearch in Google Scholar
  • 2 Conio M, Ponchon T, Blanchi S. et al . Endoscopic mucosal resection.  Am J Gastroenterol. 2006;  101 653-663
    CrossrefPubMedSearch in Google Scholar
  • 3 Gotoda T. Endoscopic resection of early gastric cancer.  Gastric Cancer. 2007;  10 1-11
    CrossrefPubMedSearch in Google Scholar
  • 4 Kantsevoy S V, Adler D G, Conway J D. et al . ASGE Technology Committee. Endoscopic mucosal resection and endoscopic submucosal dissection.  Gastrointest Endosc. 2008;  68 11-18
    CrossrefPubMedSearch in Google Scholar
  • 5 Soetikno R M, Gotoda T, Nakanishi Y. et al . Endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 567-579
    CrossrefPubMedSearch in Google Scholar
  • 6 Kim J J, Lee J H, Jung H Y. et al . EMR for early gastric cancer in Korea: a multicentre retrospective study.  Gastrointest Endosc. 2007;  66 693-700
    CrossrefPubMedSearch in Google Scholar
  • 7 Makuuchi H. Endoscopic mucosal resection for mucosal cancer in the esophagus.  Gastrointest Endosc Clin N Am. 2001;  11 445-458
    PubMedSearch in Google Scholar
  • 8 Sano Y, Machida H, Fu K I. et al . Endoscopic mucosal resection and submucosal dissection method for large colorectal tumors.  Dig Endosc. 2004;  16 S93-S96
    CrossrefPubMedSearch in Google Scholar
  • 9 Pech O, May A, Gossner L. et al . Curative endoscopic therapy in patients with early esophageal squamous-cell carcinoma or high-grade intraepithelial neoplasia.  Endoscopy. 2007;  39 30-35
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Ciocirlan M, Lapalus M G, Hervieu V. et al . Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus.  Endoscopy. 2007;  39 24-29
    Thieme ConnectPubMedSearch in Google Scholar
  • 11 Ell C, May A, Pech O. et al . Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer).  Gastrointest Endosc. 2007;  65 3-10
    CrossrefPubMedSearch in Google Scholar
  • 12 Kaltenbach T, Friedland S, Maheshwari A. et al . Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions larger than 1 cm (with video).  Gastrointest Endosc. 2007;  65 857-865
    CrossrefPubMedSearch in Google Scholar
  • 13 Bories E, Pesenti C, Monges G. et al . Endoscopic mucosal resection for advanced sessile adenoma and early-stage colorectal carcinoma.  Endoscopy. 2006;  38 231-235
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Hurlstone D P, Sanders D S, Cross S S. et al . Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection.  Gut. 2004;  53 1334-1339
    CrossrefPubMedSearch in Google Scholar
  • 15 Arebi N, Swain D, Suzuki N. et al . Endoscopic mucosal resection of 161 cases of large sessile or flat colorectal polyps.  Scand J Gastroenterol. 2007;  42 859-866
    CrossrefPubMedSearch in Google Scholar
  • 16 McCashland T M, Brand R, Lyden E. et al . Gender differences in colorectal polyps and tumors.  Am J Gastroenterol. 2001;  96 882-886
    CrossrefPubMedSearch in Google Scholar
  • 17 Harewood G C, Lieberman D A. Prevalence of advanced neoplasia at screening colonoscopy in men in private practice versus academic and Veterans Affairs medical centers.  Am J Gastroenterol. 2003;  98 2312-2316
    CrossrefPubMedSearch in Google Scholar
  • 18 Lieberman D A, Holub J, Eisen G. et al . Utilization of colonoscopy in the United States: results from a national consortium.  Gastrointest Endosc. 2005;  62 875-883
    CrossrefPubMedSearch in Google Scholar
  • 19 Lieberman D, Fennerty M B, Morris C D. et al . Endoscopic evaluation of patients with dyspepsia: results from the national endoscopic data repository.  Gastroenterology. 2004;  127 1067-1075
    CrossrefPubMedSearch in Google Scholar
  • 20 Boonpongmanee S, Fleischer D E, Pezzullo J C. et al . The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated.  Gastrointest Endosc. 2004;  59 788-794
    CrossrefPubMedSearch in Google Scholar
  • 21 Kovalak M, Lake J, Mattek N. et al . Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database.  Gastrointest Endosc. 2007;  65 82-88
    CrossrefPubMedSearch in Google Scholar
  • 22 Dickman R, Mattek N, Holub J. et al . Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database.  Am J Gastroenterol. 2007;  102 1173-1179
    CrossrefPubMedSearch in Google Scholar
  • 23 Sonnenberg A, Amorosi S L, Lacey M J. et al . Patterns of endoscopy in the United States: analysis of data from the Centres for Medicare and Medicaid Services and the National Endoscopic Database.  Gastrointest Endosc. 2008;  67 489-496
    CrossrefPubMedSearch in Google Scholar
  • 24 Canard J M, Debette-Gratien M, Dumas R. et al . A prospective national study on colonoscopy and sigmoidoscopy in 2000 in France.  Gastroenterol Clin Biol. 2005;  29 17-22
    CrossrefPubMedSearch in Google Scholar
  • 25 Bowles C JA, Leicester R, Romaya C. et al . A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?.  Gut. 2004;  53 277-283
    CrossrefPubMedSearch in Google Scholar
  • 26 Sharma V K, Nguyen C C, Crowell M D. et al . A national study of cardiopulmonary unplanned events after GI endoscopy.  Gastrointest Endosc. 2007;  66 27-34
    CrossrefPubMedSearch in Google Scholar
  • 27 Moayyedi P, Burch N, Akhtar-Danesh N. et al . Mortality rates in patients with Barrett’s oesophagus.  Aliment Pharmacol Ther. 2008;  27 316-320
    CrossrefPubMedSearch in Google Scholar
  • 28 Rastogi A, Puli S, El-Serag H B. et al . Incidence of esophageal adenocarcinoma in patients with Barrett’s esophagus and high-grade dysplasia: a meta-analysis.  Gastrointest Endosc. 2008;  67 394-398
    CrossrefPubMedSearch in Google Scholar
  • 29 Thomas T, Abrams K R, de Caestecker J S. et al . Meta analysis: cancer risk in Barrett’s oesophagus.  Aliment Pharmacol Ther. 2007;  26 1465-1477
    CrossrefPubMedSearch in Google Scholar
  • 30 de Vries A C, Meijer G A, Looman C WN. et al . Epidemiological trends of pre-malignant gastric lesions: a long-term nationwide study in the Netherlands.  Gut. 2007;  56 1665-1670
    CrossrefPubMedSearch in Google Scholar
  • 31 Pox C, Schmiegel W, Classen M. Current status of screening colonoscopy in Europe and in the United States.  Endoscopy. 2007;  39 168-173
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Singh N, Harrison M, Rex D K. A survey of colonoscopic polypectomy practices among clinical gastroenterologists.  Gastrointest Endosc. 2004;  60 414-418
    CrossrefPubMedSearch in Google Scholar
  • 33 Grasset D, Morfoisse J J, Seigneuric C. Association Nationale des Gastroentérologues des Hôpitaux non universitaires (ANGH) . Conditions de réalisation et résultat des coloscopies réalisées dans les hôpitaux non universitaires. Résultats d’une enquête transversale multicentrique de l’ANGH.  Gastroenterol Cin Biol. 2000;  24 273-278
    PubMedSearch in Google Scholar
  • 34 Ahmad N A, Kochman M L, Long W B. et al . Efficacy safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases.  Gastrointest Endosc. 2002;  55 390-396
    CrossrefPubMedSearch in Google Scholar
  • 35 Kodama M, Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of responses to a questionnaire on superficial cancer of the esophagus in Japan.  Surgery. 1998;  123 432-439
    CrossrefPubMedSearch in Google Scholar
  • 36 Katada C, Muto M, Momma K. et al . Clinical outcome after endoscopic mucosal resection for esophageal squamous cell carcinoma invading the muscularis mucosae. A multicenter retrospective cohort study.  Endoscopy. 2007;  39 779-783
    Thieme ConnectPubMedSearch in Google Scholar
  • 37 Ishihara R, Iishi H, Takeuchi Y. et al . Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection.  Gastrointest Endosc. 2008;  67 799-804
    CrossrefPubMedSearch in Google Scholar
  • 38 Ishihara R, Iishi H, Uedo N. et al . Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan.  Gastrointest Endosc. 2008;  68 1066-1072
    CrossrefPubMedSearch in Google Scholar
  • 39 Seewald S, Akaraviputh T, Seitz U. et al . Circumferential EMR and complete removal of Barrett’s epithelium: a new approach to management of Barrett’s esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma.  Gastrointest Endosc. 2003;  57 854-859
    CrossrefPubMedSearch in Google Scholar
  • 40 Giovannini M, Bories E, Presenti C. et al . Circumferential endoscopic mucosal resection in Barrett’s esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients.  Endoscopy. 2004;  36 782-787
    Thieme ConnectPubMedSearch in Google Scholar
  • 41 Peters F P, Kara M A, Rosmolen W D. et al . Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett’s esophagus.  Gastrointest Endosc. 2005;  61 506-514
    CrossrefPubMedSearch in Google Scholar
  • 42 Peters F P, Kara M A, Rosmolen W D. et al . Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study.  Am J Gastroenterol. 2006;  101 1449-1457
    CrossrefPubMedSearch in Google Scholar
  • 43 Larghi A, Lightdale C J, Ross A S. et al . Long-term follow-up of complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma.  Endoscopy. 2007;  39 1086-1091
    Thieme ConnectPubMedSearch in Google Scholar
  • 44 Ida K, Nakazawa S, Yoshirno J. et al . Multicentre collaborative prospective study of endoscopic treatment of early gastric cancer.  Dig Endosc. 2004;  16 295-302
    CrossrefPubMedSearch in Google Scholar
  • 45 Watanabe K, Ogata S, Kawazoe S. et al . Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection.  Gastrointest Endosc. 2006;  63 776-782
    CrossrefPubMedSearch in Google Scholar
  • 46 Yoshida S, Kozu T, Gotoda T. et al . Detection and treatment of early cancer in high-risk populations.  Best Pract Res Clin Gastroenterol. 2006;  20 745-765
    CrossrefPubMedSearch in Google Scholar
  • 47 Oka S, Tanaka S, Kaneko I. et al . Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer.  Gastrointest Endosc. 2006;  64 877-883
    CrossrefPubMedSearch in Google Scholar
  • 48 Ishikawa S, Togashi A, Inoue M. et al . Indications for EMR/ESD in cases of early gastric cancer: relationship between histological type, depth of wall invasion, and lymph node metastasis.  Gastric Cancer. 2007;  10 35-38
    CrossrefPubMedSearch in Google Scholar
  • 49 Park Y D, Chung Y J, Chung H Y. et al . Factors related to lymph node metastasis and the feasibility of endoscopic mucosal resection for treating poorly differentiated adenocarcinoma of the stomach.  Endoscopy. 2008;  40 7-10
    Thieme ConnectPubMedSearch in Google Scholar
  • 50 Conio M, Repici A, Demarquay J F. et al . EMR of large sessile colorectal polyps.  Gastrointest Endosc. 2004;  60 234-241
    CrossrefPubMedSearch in Google Scholar
  • 51 Su M Y, Hsu C M, Ho Y P. et al . Endoscopic mucosal resection for colonic non-polypoid neoplasms.  Am J Gastroenterol. 2005;  100 2174-2179
    CrossrefPubMedSearch in Google Scholar
  • 52 Uraoka T, Saito Y, Matsuda T. et al . Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum.  Gut. 2006;  55 1592-1597
    CrossrefPubMedSearch in Google Scholar
  • 53 Gotoda T, Kaltenbach T, Soetikno R. Is en bloc resection essential for endoscopic resection of GI neoplasia?.  Gastrointest Endosc. 2008;  67 805-807
    CrossrefPubMedSearch in Google Scholar
  • 54 Esaki M, Matsumoto T, Hirakawa K. et al . Risk factors for local recurrence of superficial esophageal cancer after treatment by endoscopic mucosal resection.  Endoscopy. 2007;  39 41-45
    Thieme ConnectPubMedSearch in Google Scholar
  • 55 Higuchi K, Tanabe S, Koizumi W. et al . Expansion of the indications for endoscopic mucosal resection in patients with superficial esophageal carcinoma.  Endoscopy. 2007;  39 36-40
    Thieme ConnectPubMedSearch in Google Scholar
  • 56 Lépilliez V, Chemaly M, Ponchon T. et al . Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding.  Endoscopy. 2008;  40 806-810
    Thieme ConnectPubMedSearch in Google Scholar
  • 57 Ueno H, Mochizuki H, Hashiguchi Y. et al . Risk factors for an adverse outcome in early invasive colorectal carcinoma.  Gastroenterology. 2004;  127 385-394
    CrossrefPubMedSearch in Google Scholar
  • 58 Nakajo K, Tamura S, Hiroi M. et al . Evaluation of the risk factors of lymph node metastasis in PT1 stage colorectal carcinoma: indication for an endoscopic mucosal resection.  Dig Endosc. 2007;  19 174-179
    CrossrefPubMedSearch in Google Scholar
  • 59 Prasad G A, Buttar N S, Wongkeesong L M. et al . Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett’s esophagus.  Am J Gastroenterol. 2007;  102 2380-2386
    CrossrefPubMedSearch in Google Scholar
  • 60 Volk E E, Goldblum J R, Petras R E. et al . Management and outcome of patients with invasive carcinoma arising in colorectal polyps.  Gastroenterology. 1995;  109 1801-1807
    CrossrefPubMedSearch in Google Scholar
  • 61 Cooper H S, Deppisch L M, Gourley W K. et al . Endoscopically removed malignant colorectal polyps: clinicopathologic correlations.  Gastroenterology. 1995;  108 1657-1665
    CrossrefPubMedSearch in Google Scholar
  • 62 Uno Y, Munakata A. The non-lifting sign of invasive colon cancer.  Gastrointest Endosc. 1994;  40 485-489
    CrossrefPubMedSearch in Google Scholar
  • 63 Ishiguro A, Uno Y, Ishiguro Y. et al . Correlation of lifting versus non-lifting and microscopic depth of invasion in early colorectal cancer.  Gastrointest Endosc. 1999;  50 329-333
    CrossrefPubMedSearch in Google Scholar
  • 64 Kobayashi N, Saito Y, Sano Y. et al . Determining the treatment strategy for colorectal neoplastic lesions: endoscopic assessment or the non-lifting sign for diagnosing invasion depth?.  Endoscopy. 2007;  39 701-705
    Thieme ConnectPubMedSearch in Google Scholar
  • 65 May A, Günter E, Roth F. et al . Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial.  Gut. 2004;  53 634-640
    CrossrefPubMedSearch in Google Scholar
  • 66 Pech O, Behrens A, May A. et al . Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus.  Gut. 2008;  57 1200-1206
    CrossrefPubMedSearch in Google Scholar
  • 67 Saitoh Y, Obara T, Einami K. et al . Efficacy of high-frequency ultrasound probes for the preoperative staging of invasion depth in flat and depressed colorectal tumors.  Gastrointest Endosc. 1996;  44 34-39
    CrossrefPubMedSearch in Google Scholar
  • 68 Hurlstone D P, Brown S, Cross S S. et al . High magnification chromoscopic colonoscopy or high frequency 20 MHz mini probe endoscopic ultrasound staging for early colorectal neoplasia: a comparative prospective analysis.  Gut. 2005;  54 1585-1589
    CrossrefPubMedSearch in Google Scholar
  • 69 Pech O, Günter E, Ell C. Endosonography of high-grade intra-epithelial neoplasia/early cancer.  Best Pract Res Clin Gastroenterol. 2009;  23 639-647
    CrossrefPubMedSearch in Google Scholar
  • 70 Rampado S, Bocus P, Battaglia G. et al . Endoscopic ultrasound: accuracy in staging superficial carcinomas of the esophagus.  Ann Thorac Surg. 2008;  85 251-256
    CrossrefPubMedSearch in Google Scholar

D. HeresbachMD, PhD 

Service des Maladies de l’Appareil Digestif – CHU Pontchaillou

35033 – Rennes Cedex 09
France

Email: denis.heresbach@chu-rennes.fr