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A minimally invasive treatment for early GI cancers

Cleveland Clinic Journal of Medicine. 2017 September;84(9):707-717 | 10.3949/ccjm.84a.16063
September 1, 2017|Cleveland Clinic Journal of Medicine
Lady Katherine Mejía-Pérez, MD;Seiichiro Abe, MD;Tyler Stevens, MD;Mansour A. Parsi, MD;Sunguk N. Jang, MD;Ichiro Oda, MD;John J. Vargo, MD, MPH;Yutaka Saito, MD, PhD;Amit Bhatt, MD
Author and Disclosure Information

Lady Katherine Mejía-Pérez, MD
Department of Internal Medicine, Cleveland Clinic

Seiichiro Abe, MD
Endoscopy Division, National Cancer Center Hospital,  Tokyo, Japan

Tyler Stevens, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Mansour A. Parsi, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

Sunguk N. Jang, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

Ichiro Oda, MD
Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

John J. Vargo, MD, MPH
Chairman, Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Yutaka Saito, MD, PhD
Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

Amit Bhatt, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Amit Bhatt, MD, Department of Gastroenterology and Hepatology, Digestive Disease Institute, A30, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; bhatta3@ccf.org

ABSTRACT

Endoscopic submucosal dissection (ESD) allows curative resection of early malignant gastrointestinal (GI) lesions, potentially avoiding open surgery. Unfortunately, awareness of this technique is low, and many patients undergo surgery without consideration of ESD. This article reviews the indications for ESD and its advantages and limitations, and guides internists in their approach to patients with early GI cancer.

KEY POINTS

  • ESD is a minimally invasive endoscopic technique with curative potential for patients with superficial GI neoplasia.
  • ESD preserves the integrity of the organ while achieving curative resection of large neoplasms.
  • ESD is indicated rather than surgery in patients with early GI lesions with a negligible risk of lymph node metastasis.
  • Complications of the procedure include bleeding, perforation, and stenosis. Most of these respond to endoscopic treatment.
  • Successful ESD requires supportive teamwork among internists, gastroenterologists, pathologists, and surgeons.

COLORECTAL CANCER

Indications for ESD for colorectal cancer in the East

Colon cancer is one of the leading causes of cancer-related deaths worldwide.58 Since ESD has been found to be effective and safe in treating gastric cancer, it has also been used to remove large colorectal tumors.59 However, ESD is not universally accepted in the treatment of colorectal neoplasms due to its greater technical difficulty, longer procedural time, and higher risk of perforating the thinner colonic wall compared with EMR.21,60

According to the Japanese Society of Gastroenterology, ESD should be reserved for lesions that are not amenable to snare removal (> 20 mm in size, intramucosal tumors with fibrosis, localized lesions that result from chronic inflammation, and local residual carcinoma) (Tables 4 and 5).21,61 Colorectal ESD should be performed only by a trained endoscopist.11

Outcomes for colorectal cancer

Piecemeal resection is one of the predictors of recurrence after endoscopic removal of colorectal cancer.62 Therefore, the cumulative rates of en bloc resection and curative resection are higher and the recurrence rate is lower for en bloc ESD than for EMR.62–65 Complication rates and procedural time are higher for ESD than for EMR.59,66

Tumor size of 50 mm or larger is a risk factor for complications, while a high procedure volume at the center is a protective factor.60

Endoscopic treatment of colorectal cancer: The Western perspective

EMR is the gold standard for removal of superficial colorectal lesions. However, ESD can be considered if there is suspicion of superficial submucosal invasion, especially for lesions larger than 20 mm that cannot be resected en bloc by EMR.32 ESD can also be used for fibrotic lesions not amenable to complete EMR removal, or as a salvage procedure after recurrence after EMR.67 Proper selection of cases is critical.1

Patients who have a superficial colonic lesion should be evaluated by means of high-definition endoscopy and chromoendoscopy to assess the mucosal pattern and establish feasibility of endoscopic resection. If submucosal invasion is suspected, staging with endoscopic ultrasonography or magnetic resonance imaging should be considered.5

FOLLOW-UP AFTER ESD

Endoscopic surveillance after the procedure is recommended, given the persistent risk of metachronous cancer after curative ESD due to its organ-sparing quality.68 Surveillance endoscopy aims to achieve early detection and subsequent endoscopic resection of metachronous lesions.

Histopathologic evaluation assessing the presence of malignant cells in the margins of a resected sample is mandatory for determining the next step in treatment. If margins are negative, follow-up endoscopy can be done every 6 to 12 months. If margins are positive, the approach includes surgery, reattempting ESD or endoscopic surveillance in 3 or 6 months.3,32 Although the surveillance strategy varies according to individual risk of metachronous cancer, it should be continued indefinitely.68

COMPLICATIONS OF ESD

The most common procedure-related complications of ESD are bleeding, perforation, and stricture. Most intraprocedural adverse events can be managed endoscopically.69

Bleeding

Most bleeding occurs during the procedure or early after it and can be controlled with electrocautery.49,69 No episodes of massive bleeding, defined as causing clinical symptoms and requiring transfusion or surgery, have been reported.20,43,55

In gastric ESD, delayed bleeding rates have ranged from 0 to 15.6%.69 Bleeding may be prevented with endoscopic coagulation of visible vessels after dissection has been completed and by proton pump inhibitor therapy.70,71 Excessive coagulation should be avoided to lower the risk of perforation.33

In colorectal ESD the bleeding rate has been reported to be 2.2%; applying coagulation to an area where a blood vessel is suspected before cutting (precoagulation) may prevent subsequent bleeding.21

Perforation

For gastric ESD, perforation rates range from 1.2% to 5.2%.69 Esophageal perforation rates can be up to 4%.49 In colorectal ESD, perforation rates have been reported to be 1.6% to 6.6%.60,72

Although most of the cases were successfully managed with conservative treatment, some required emergency surgery.60,73

Strictures

In a case series of 532 patients undergoing gastric ESD, stricture was reported in 5 patients, all of whom presented with obstructive symptoms.74 Risk factors for post-ESD gastric stenosis are a mucosal defect with a circumferential extent of more than three-fourths or a longitudinal extent of more than 5 cm.75

Strictures are common after esophageal ESD, with rates ranging from 2% to 26%. The risk is higher when longer segments are removed or circumferential resection is performed. As previously mentioned, this complication may be reduced with ingestion or injection of steroids  after the procedure.53,54

Surprisingly, ESD of large colorectal lesions involving more than three-fourths of the circumference of the rectum is rarely complicated by stenosis.76

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