Introduction Endoscopic submucosal dissection (ESD) is recognised in Japan as an effective therapeutic modality for the clearance of gastrointestinal neoplasms, providing an en bloc specimen to confirm lateral and deep resection margins and minimising the risk of recurrence. However, due to the technical complexity, prolonged procedure time and risk of complications, few European centres have introduced this technique. This study assessed the feasibility and efficacy of ESD and hybrid ESD/P-EMR (piecemeal endoscopic mucosal resection) in a UK setting.
Methods ESD was performed with either a “Flex knife” (Olympus) in the earliest cases and a “Flush knife” (Fujinon) in the later cases. After initial experience of five ESD procedures, in order to accelerate the procedure time, a decision was made to convert to hybrid ESD/P-EMR for the cases in which submucosal dissection was not progressing rapidly, that is <30% of a lesion had been resected at 1 h after starting the procedure. The following factors; patient and lesion characteristics, sedation used, achievement of en-bloc resection, histology, complications and follow-up data were recorded prospectively.
Result Twenty-six colorectal and four gastric lesions were removed by ESD. The resected lesions were between 10 mm and 90 mm in diameter (median 50 mm) and included six “salvage” procedure where recurrence had occurred after previously attempted endosocpic snare resection. Three patients received propfol sedation and 27 patients received conscious sedation with midazolam (mean 2.52 mg) and pethidine (mean 50 mg). ESD was completed in 18 cases and ESD abandoned in one case due to suspecting deep cancer invasion. The rest (11) was treated with ESD/EMR hybrid. The mean procedure time was 120 min (20–300 min) for ESD and 111 min (49–172 min) for ESD/P-EMR hybrid. En-bloc resection was achieved in 20/30 patients. 18 patients were hospitalised overnight and the rest were treated as a day case. The only major complication was post polypectomy bleeding in two patients 14 days and 10 days after the procedure, respectively, which required a 2-unit blood transfusion in one case but no endoscopic or surgical intervention. Histopathologically, 28 lesions were benign and two lesions were adenocarcinomas. One of which was sm1 cancer which was completely removed. In the other case, the procedure was abandoned and sent for surgery. Twenty-five out of 30 patients had follow-up examinations between 3–6 months after the initial procedure and 23/25 patients were free of recurrence.
Conclusion ESD appears to be feasible and effective for the excision of selected colorectal and gastric lesions with an acceptable safety profile. After introducing the ESD/P-EMR hybrid policy, no procedure time exceeded 3 h apart from one case with a 9 cm rectal lesion.
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