Endoscopic Submucosal Dissection in Patients with Ulcerative Colitis

Abstract

Patients with ulcerative colitis have an increased risk of developing colorectal cancer. This risk has been estimated to reach about 7% at 20 years of disease, 7–14% at 25 years, and as high as 30% after 35 years. The guidelines for the management of inflammatory bowel disease recommend endoscopic resection of circumscribed dysplasia and ongoing colonoscopic surveillance as a reasonable strategy in patients with ulcerative colitis. Submucosal fibrosis due to background inflammation could hamper adequate lifting and endoscopic treatment. Endoscopic mucosal resection (EMR) is difficult for dysplasia within colitic mucosa due to the non-lifting sign. Although endoscopic submucosal dissection (ESD) generally has higher risks of perforation and bleeding compared to EMR, the technique can achieve complete en bloc resection regardless of the lesion size or severity of submucosal fibrosis. Several studies have shown that ESD for circumscribed dysplasia in ulcerative colitis is feasible. While ESD can avert unnecessary surgery, submucosal fibrosis makes the intervention technically demanding in cases of ulcerative colitis. ESD should be performed by expert endoscopists using the most suitable equipment and devices available.

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

“…When we undertake piecemeal resections during EMR, we carefully evaluate the stump of the ulcer, and additional mucosal cautery trimming is performed, where necessary, which may reduce the risk of local recurrence. While local recurrence (0%–22.2%) and R0 resection rates (77%–80%) have been reported following ESD of tumors in patients with UC, 9,11,12,21,30 our lower local recurrence rate corresponded with a higher R0 resection rate (97%) compared with those reported previously.…”

Endoscopic diagnosis and treatment of ulcerative colitis‐associated neoplasia

“…Endoscopic resection, including ESD, is a therapeutic technique and is simultaneously an important diagnostic method for determining the need for a total excisional biopsy to investigate the histological diversity of the completely resected specimen. According to the responses to this questionnaire, ESD is recognized as a standard en bloc endoscopic method for UCAN . Japanese guidelines strongly recommend considering sporadic localized tumors in chronic inflammatory conditions such as UC as one of the indications for colorectal ESD .…”

Endoscopic submucosal dissection for colorectal dysplasia in inflammatory bowel disease: a US multicenter study

“…The ASGE practice guidelines recommend en bloc resection of raised, endoscopically visible, dysplastic lesions with distinct borders in regions of chronic active colitis that might be prone to fibrosis by EMR or ESD 4 . However, to date, the outcomes data on colorectal ESD for the management of IBD-associated dysplastic lesions are scarce and limited to studies from Asia and Europe 7 8 9 10 11 12 . In this US multicenter study on clinical outcomes of ESD in IBD, we found that ESD was associated with high en bloc (95.6 %) and R0 resection rates (75.5 %), with a median lesion size of 30 mm.…”

“…ESD was performed as previously described ( Fig. 1 ) 7 8 . In brief, the procedures were performed using either an adult or pediatric colonoscope, or an upper endoscope for lesions within reach.…”

“…Although the procedure is technically difficult because of high prevalence of submucosal fibrosis, several recent small studies from Asia and Europe, have indicated that ESD is a safe and effective treatment for dysplastic lesions in the setting of IBD 7 8 9 10 11 12 . ESD is a potential alternative treatment option when EMR is not feasible or does not enable en bloc removal of larger lesions.…”