Implementation of Endoscopic Submucosal Dissection in a Western Institution
(2019) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2019(95).- Abstract
- Endoscopic resection of colorectal polyps reduce morbidity and mortality from colorectal cancer (CRC).
Endoscopic submucosal dissection (ESD) is a highly efficient and established method for treating advanced colorectal lesions in Asia, but experience of ESD in Western countries is limited. Large non-pedunculated colorectal lesions are prone to malignant transformation and it is therefore important to resect these lesions in one piece (en bloc), which is obtainable with ESD but not with traditional endoscopic resection techniques.
This thesis focused on the implementation of ESD at the endoscopy center, Skåne University Hospital, Malmö. It was found that the learning curve of colorectal ESD is long and steep but excellent results... (More) - Endoscopic resection of colorectal polyps reduce morbidity and mortality from colorectal cancer (CRC).
Endoscopic submucosal dissection (ESD) is a highly efficient and established method for treating advanced colorectal lesions in Asia, but experience of ESD in Western countries is limited. Large non-pedunculated colorectal lesions are prone to malignant transformation and it is therefore important to resect these lesions in one piece (en bloc), which is obtainable with ESD but not with traditional endoscopic resection techniques.
This thesis focused on the implementation of ESD at the endoscopy center, Skåne University Hospital, Malmö. It was found that the learning curve of colorectal ESD is long and steep but excellent results in terms of efficacy and safety, can be reached. Thus, the en bloc rate increased from 60% to 98% during a five year long learning period comprising 301 lesions. However, lesions located in the proximal colon are challenging and all patients requiring emergency surgery (2%) had proximal colonic lesions. The role of ESD in resecting malignant colorectal lesions was also studied. Curative resection was obtained in 38% of malignant ESD resections according to current guidelines, but ESD served as final treatment in 76% of the patients. Thus this thesis provide evidence that colorectal ESD is highly feasible in the West and is an eligible method for advanced polyps and early CRC, limiting surgery to cases with a high risk of lymph node metastases (LNM).
Forceps biopsies are routinely obtained in the work up of colorectal lesions referred for endoscopic resection in the West. However, the reliability of biopsies in large colorectal lesions is unknown. In this thesis, we studied the accuracy of biopsies in reflecting the histology of large colorectal lesions and found biopsies to be concordant to resected specimen in 61%. Hence, biopsies underestimated and overestimated histologic grade of colorectal lesions in 29% and 9%, respectively. These findings question the role of forceps biopsies in the routine work up of lesions amenable to endoscopic resection.
Endoscopic resection of early CRC cancer is feasible, as shown in this thesis, although the risk of LNM and recurrence cannot be ignored. The risk of LNM, currently assessed mainly by depth of submucosal invasion, is decisive whether subsequent surgery or surveillance is recommended. In this thesis, we investigated risk factors of LNM in T1 CRC, and found that depth of submucosal invasion is not an independent risk factor of LNM.
Lymphovascular invasion was the dominating risk factor with 40% risk of LNM when present. Mucinous subtype, perineural invasion and low age were also independent risk factors. Our findings are somewhat in contrast to current guidelines and provide new evidence for which risk factors to assess when managing locally resected T1 CRC. (Less)
Please use this url to cite or link to this publication:
https://lup.lub.lu.se/record/be0ad587-e15e-4280-b38a-ca12059291ef
- author
- Rønnow, Carl-Fredrik LU
- supervisor
-
- Henrik Thorlacius LU
- Ervin Toth LU
- Bengt Jeppsson LU
- opponent
-
- MD, PhD, Professor of Medicine Yahagi, Naohisa, Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- organization
- publishing date
- 2019
- type
- Thesis
- publication status
- published
- subject
- in
- Lund University, Faculty of Medicine Doctoral Dissertation Series
- volume
- 2019
- issue
- 95
- pages
- 101 pages
- publisher
- Lund University: Faculty of Medicine
- defense location
- Agardh föreläsningssal, CRC, Jan Waldenströms gata 35, Skånes Universitetssjukhus i Malmö
- defense date
- 2019-10-18 13:00:00
- ISSN
- 1652-8220
- ISBN
- 978-91-7619-824-7
- language
- English
- LU publication?
- yes
- id
- be0ad587-e15e-4280-b38a-ca12059291ef
- date added to LUP
- 2019-09-12 19:54:10
- date last changed
- 2023-02-23 13:29:35
@phdthesis{be0ad587-e15e-4280-b38a-ca12059291ef,
abstract = {{Endoscopic resection of colorectal polyps reduce morbidity and mortality from colorectal cancer (CRC).<br/>Endoscopic submucosal dissection (ESD) is a highly efficient and established method for treating advanced colorectal lesions in Asia, but experience of ESD in Western countries is limited. Large non-pedunculated colorectal lesions are prone to malignant transformation and it is therefore important to resect these lesions in one piece (en bloc), which is obtainable with ESD but not with traditional endoscopic resection techniques.<br/>This thesis focused on the implementation of ESD at the endoscopy center, Skåne University Hospital, Malmö. It was found that the learning curve of colorectal ESD is long and steep but excellent results in terms of efficacy and safety, can be reached. Thus, the en bloc rate increased from 60% to 98% during a five year long learning period comprising 301 lesions. However, lesions located in the proximal colon are challenging and all patients requiring emergency surgery (2%) had proximal colonic lesions. The role of ESD in resecting malignant colorectal lesions was also studied. Curative resection was obtained in 38% of malignant ESD resections according to current guidelines, but ESD served as final treatment in 76% of the patients. Thus this thesis provide evidence that colorectal ESD is highly feasible in the West and is an eligible method for advanced polyps and early CRC, limiting surgery to cases with a high risk of lymph node metastases (LNM).<br/>Forceps biopsies are routinely obtained in the work up of colorectal lesions referred for endoscopic resection in the West. However, the reliability of biopsies in large colorectal lesions is unknown. In this thesis, we studied the accuracy of biopsies in reflecting the histology of large colorectal lesions and found biopsies to be concordant to resected specimen in 61%. Hence, biopsies underestimated and overestimated histologic grade of colorectal lesions in 29% and 9%, respectively. These findings question the role of forceps biopsies in the routine work up of lesions amenable to endoscopic resection.<br/>Endoscopic resection of early CRC cancer is feasible, as shown in this thesis, although the risk of LNM and recurrence cannot be ignored. The risk of LNM, currently assessed mainly by depth of submucosal invasion, is decisive whether subsequent surgery or surveillance is recommended. In this thesis, we investigated risk factors of LNM in T1 CRC, and found that depth of submucosal invasion is not an independent risk factor of LNM.<br/>Lymphovascular invasion was the dominating risk factor with 40% risk of LNM when present. Mucinous subtype, perineural invasion and low age were also independent risk factors. Our findings are somewhat in contrast to current guidelines and provide new evidence for which risk factors to assess when managing locally resected T1 CRC.}},
author = {{Rønnow, Carl-Fredrik}},
isbn = {{978-91-7619-824-7}},
issn = {{1652-8220}},
language = {{eng}},
number = {{95}},
publisher = {{Lund University: Faculty of Medicine}},
school = {{Lund University}},
series = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
title = {{Implementation of Endoscopic Submucosal Dissection in a Western Institution}},
url = {{https://lup.lub.lu.se/search/files/70250526/Carl_Fredrik_R_nnow_web_190925.pdf}},
volume = {{2019}},
year = {{2019}},
}