An endoscopic treatment strategy for superficial tumors in patients with ulcerative colitis

Abstract

Background and Aim Endoscopic resection is feasible for superficial tumors in patients with ulcerative colitis; however, endoscopic resection options have not been evaluated comprehensively. We evaluated the efficacy and safety of endoscopic submucosal dissection and endoscopic mucosal resection, and decision making regarding endoscopic resection options for patients with ulcerative colitis. Methods Endoscopically treated tumors from patients with ulcerative colitis were analyzed retrospectively. We evaluated en bloc and R0 resection, adverse events, local tumor recurrence, and metachronous lesion occurrence rates. Results We examined 102 tumors (mean size, 12 mm; non‐polypoid, 55 tumors) from 74 patients with ulcerative colitis, of whom, 39 and 63 underwent endoscopic submucosal dissection and endoscopic mucosal resection, respectively. The R0 resection rate was significantly higher for endoscopic submucosal dissection (97%) than for endoscopic mucosal resection (80%) (P = 0.0015). For 11–20‐mm tumors, the R0 resection rate was significantly higher for endoscopic submucosal dissection (94%) than for endoscopic mucosal resection (55%) (P = 0.0027); the endoscopic submucosal dissection and endoscopic mucosal resection R0 rates did not differ for ≤ 10‐mm tumors. The non‐polypoid tumor R0 resection rates were significantly higher for endoscopic submucosal dissection (100%) than for endoscopic mucosal resection (65%) (P < 0.001) and did not differ regarding the polypoid tumor R0 resection rates (75% vs 86%, P = 0.49). Four patients experienced intraoperative perforation during endoscopic submucosal dissection. No local recurrences occurred. Metachronous high‐grade dysplasia occurred in three patients during surveillance. Conclusions In patients with ulcerative colitis, endoscopic submucosal dissection is suitable for ≥ 11‐mm and non‐polypoid tumors, whereas endoscopic mucosal resection is acceptable for ≤ 10‐mm tumors.

Recent Advance in the Management of Dysplasia in the Ulcerative Colitis

“…In addition to relative indistinctness of lesion borders, submucosal fibrosis is a common hurdle for successful ESD in colitis-associated dysplasia. The frequency of submucosal fibrosis ranged 66% to 100% according to several small ESD studies for UC or IBD patients [29][30][31][32][33][34]. Despite these challenges, en bloc resection and histologic complete resection rates of ESD for colitis-associated dysplasia ranged 80% to 100% and 67% to 97%, respectively in these studies.…”

“…Because of submucosal fibrosis resulted from long-standing inflammation, colitis-associated dysplasia is difficult to remove in en bloc manner. According to a recent retrospective study from Japan [34], when removing 10 mm or larger superficial tumors in UC patients, ESD showed superior histologically complete resection rate to EMR. The histologic complete resection rate of non-polypoid tumors was also higher in the ESD group than the EMR group [34].…”

“…Nonetheless, recent guidelines suggest surveillance rather than colectomy if a non-polypoid dysplasia was completely re-moved via endoscopic resection and no synchronous nonpolypoid dysplasia is present (Table 2) [11,27,28]. Recently, several small studies reported the outcomes of endoscopic resection of non-polypoid dysplasia which were removed by using endoscopic submucosal dissection (ESD) technique [29][30][31][32][33][34]. The median duration of follow-up in these studies is relatively short ranging from 21 to 37 months [29][30][31][32][33],…”

“…except one study included 7 ESD cases of non-polypoid dysplasia of which median follow-up duration was 180 months (range, 105-271) [34]. In these studies, there was no CRC during the relative short follow-up and long-term outcome of endoscopic treatment for non-polypoid dysplasia should be investigated.…”

Underwater endoscopic mucosal resection for a sporadic adenoma located at severe longitudinal ulcer scars in ulcerative colitis

“…Histopathological examination revealed a lowgrade tubular adenoma without tumor involvement on the horizontal and vertical margins. Conventional endoscopic mucosal resection (EMR) of polyps on severe scars due to UC is technically challenging [1] because submucosal fibrosis from background inflammation makes it difficult to lift the lesion during submucosal injection and to snare the entire tumor. UEMR has been reported to be an effective technique in cases of severe submucosal fibrosis [2][3][4][5], but it has not been performed in patients with UC after healing from inflammation.…”