The efficacy of the pocket-creation method for cases with severe fibrosis in colorectal endoscopic submucosal dissection

Abstract

Background and study aims Severe fibrosis poses a challenge in colorectal endoscopic submucosal dissection (ESD). Recently, the pocket-creation method (PCM) has been developed for overcoming various difficulties of ESD. A specific tapered hood is used for adequate traction in the PCM, and endoscopic operability becomes stable in the pocket. In this study, we investigated the efficacy of the PCM in ESD for cases with severe fibrosis. Patients and methods We retrospectively reviewed 1000 consecutive colorectal ESD cases (April 2006 to January 2017). Since 2016, the PCM was performed in 58 cases. The indications for ESD included (1) tumors ≥ 20 mm in size diagnosed as intramucosal cancer or high-grade dysplasia and part of T1a cancer using magnifying endoscopic examinations and (2) tumors that appeared impossible to resect with endoscopic mucosal resection because of suspected fibrosis. We identified 120 cases with severe fibrosis and compared them to cases without severe fibrosis. Additionally, the 120 severe fibrosis cases were divided into the PCM and non-PCM groups. En bloc resection, procedure time, discontinuation, and complications were analyzed between these 2 groups. Results Among all 1000 ESDs, severe fibrosis and discontinuation rates were 12.0 % (120 cases) and 1.8 % (18 cases), respectively. Regarding the comparison between cases with severe fibrosis and with no severe fibrosis, there were significant differences about en bloc resection rate (78.3 % vs. 95.7 %, P < 0.001), discontinuance rate (12.5 % vs. 0.3 %, P < 0.001), and perforation rate (8.3 % vs. 2.6 %, P = 0.001). Among the 120 cases with severe fibrosis, 21 and 99 cases were in the PCM and non-PCM groups, respectively. The PCM group had a higher en bloc resection rate (95.2 vs. 74.7, P = 0.03), a shorter mean procedure time (min) (79.6 ± 26.5 vs. 118.8 ± 71.0, P = 0.001), and no cases of discontinuation. An analysis of the interobserver agreement for the diagnosis of severe fibrosis among the 3 endoscopists showed kappa values of > 0.6. Conclusions In cases with severe fibrosis, the PCM with ESD improved en bloc resection rates and shortened the procedure time compared to the conventional non-PCM method. Additionally, the PCM reduced the discontinuation rate.

The efficacy of the submucosal injection of lidocaine during endoscopic submucosal dissection for colorectal neoplasms: a multicenter randomized controlled study

“…A number of new cutting devices have been developed for easily cutting submucosal fibrosis. In addition, traction devices, such as the S-O clip [5], as well as the balloon overtube-guided technique [6] and pocket-creation methods [7] have been used to maintain a good endoscopic view. However, few procedures for controlling bowel peristalsis have been developed.…”

Efficacy of Current Traction Techniques for Endoscopic Submucosal Dissection

“…Similar findings were documented by other comparative case series. In the retrospective analysis of 1,000 colorectal ESD cases by Yoshida et al, 43 severe fibrosis compared to nonfibrotic cases were associated with lower en bloc resection rates (78.3% vs 95.7%, p<0.001), higher discontinuation rates (12.5% vs 0.3%, p<0.001), and higher perforation rates (8.3% vs 2.6%, p=0.001). By utilizing the PCM method, the endoscopists could achieve higher en bloc resection rate (95.2% vs 74.7%, p=0.03), complete resection rate (85.7% vs 54.5%, p=0.04), and a shorter mean procedural time (79.6±26.5 minutes vs 118.8±71 minutes, p=0.001) without discontinuation even in the cases of severe fibrosis.…”

“…In total, there were four RCTs and eight retrospective comparative studies reporting on traction methods for colorectal ESD fitting the criteria described under the method section (Table 3). [36][37][38][39][40][41][42][43][44][45][46][47] As mentioned in the former chapter, clip line traction is regarded as an uncomplicated technique to obtain satisfactory traction. However, it is troublesome during colorectal ESD if withdrawal of the endoscope is required to attach a string to an endoclip outside the patient, before reinsertion and continuing with the dissection.…”

ESD using the pocket‐creation method enables complete resection of lesions at an anastomotic site

“…Endoscopic submucosal dissection (ESD) is an accepted minimally invasive treatment for large colorectal lesions 1 . The pocket‐creation method (PCM) has been reported to be effective for ESD 2–4 . Patients who have undergone colorectal surgery for malignancies are still at risk of developing metachronous lesions in the residual colon including at the anastomotic site.…”