Case Reports in Medicine

Case Reports in Medicine / 2009 / Article

Case Report | Open Access

Volume 2009 |Article ID 573981 | 3 pages | https://doi.org/10.1155/2009/573981

Application of Endoscopic Submucosal Dissection for Removal of Deep Invasive Submucosal Colon Carcinoma

Academic Editor: Robert Pirker
Received30 Jan 2009
Accepted19 Jul 2009
Published19 Aug 2009

Abstract

Endoscopic submucosal (sm) dissection (ESD) is a recently used technique that enables en-bloc resection of large colorectal tumors allowing a more precise histopathological analysis of the resected specimen. However, it has not been widely adopted even in Japan mainly due to its technical difficulty and increased risk of perforation. Herein, we present an ESD-treated lesion with deep sm invasion removed without complications, such as bleeding or perforation, from a patient at high-risk for surgical intervention. A successful ESD was achieved although the sm invasion was greater than 1000 m from the muscularis mucosae, and the nonlifting sign was positive. It is our belief that this procedure should be performed at least in patients at high-risk for surgical intervention. At present, we have removed 16 lesions with deep sm invasion by ESD without complications, demonstrating that deep sm cancer can be successfully resected by this technique as a local resection. Herein, we report on one of these cases

1. Introduction

In Japan, as shown in [13], EMR is the treatment of choice for superficial early colorectal cancer due to the minimal invasiveness and efficacy of the procedure. However, when dealing with flat lesions greater than 20 mm in diameter, the rate of piecemeal resection, incomplete removal, and local recurrence after EMR increases, as discussed in [46]. Endoscopic submucosal (sm) dissection (ESD) is a recently used technique that enables en-bloc resection of large colorectal tumors allowing a more precise histopathological analysis of the resected specimen, as shown in [7, 8]. However, as cited in [9, 10], colorectal ESD has not been widely adopted even in Japan mainly due to its technical difficulty and increased risk of perforation.

Herein, we report on an ESD-treated lesion with deep sm invasion removed from a patient at highrisk for surgical intervention. The role of ESD for lesions with sm invasion greater than 1000  m from the muscularis mucosae is discussed.

2. Case Presentation

A 79-year-old male was diagnosed to have a lesion of 28 mm in diameter located in the rectosigmoid colon, with a 0- macroscopic type (Figure 1). Pathological findings of biopsy specimens revealed a well-differentiated adenocarcinoma. The nonlifting sign was positive. As discussed by Matsuda [11], high magnifying observation with crystal violet staining showed an invasive pattern with irregular and distorted epithelial crypts in the demarcated area suggesting sm invasion greater than 1000  m from the muscularis mucosae. Open surgery was the first choice offered to the patient. However, as he was considered to be at high risk for surgical intervention due to his history of two acute myocardial infarction episodes and an abdominal aorta bypass procedure, endoscopic resection of the lesion was recommended to avoid open surgery.

As decribed in [1215], under conscious sedation, with CO2 insufflation, after indigocarmine dye spraying and injection of glycerol and sodium hyaluronate acid into the sm layer, a circumferential mucosal incision was made using a bipolar current needle knife (B-knife) (XEMEX Co., Tokyo, Japan). The sm dissection was performed using a B-knife and an insulation-tipped diathermic knife (IT-knife) (Olympus Medical Systems Corp., Tokyo, Japan) providing a direct observation of the sm and muscle layers (Figure 2). The resection left an ulcer bed without muscle damage or bleeding (Figure 3). The en-bloc resection and removal of the specimen was completed in approximately 80 minutes without any complication (Figure 4). Histopathological analysis of the resected specimen showed a well-differentiated adenocarcinoma, and the depth of invasion was sm 2500  m with negative lateral and vertical margins (Figure 5).

3. Discussion

According to the Paris classification of superficial neoplastic lesions [16], lesions with sm invasion of less than 1000  m from the muscularis mucosae should be removed by ESD. In contrast, lesions with sm invasion exceeding 1000  m are currently considered for surgical resection, as shown in [17, 18]. In this particular case, due to the patient’s critical heart condition, ESD was performed although the sm invasion exceeded 1000  m in depth, and the nonlifting sign was positive.

At the National Cancer Center Hospital a total of 16 cases with deep invasive sm lesions have been successfully removed by ESD, with negative lateral and vertical margins observed during histopathological analysis of the resected specimen.

During ESD for sm cancer, a direct observation of the sm and muscle layers possibilitates a total sm resection. If the lesion has invaded the muscularis propria though, ESD should not be performed because of the risk of colonic perforation. However, as discussed by Saito [7], the use of the B-knife in ESD has decreased the perforation rate. By using this device, a safer procedure is achieved probably because the electric current is centered to the tip of the needle, as shown in [19].

This case has demonstrated that the removal of lesions with sm invasion greater than 1000  m from the muscularis mucosae can be successfully resected by ESD as a local resection. It is our belief that this procedure should become the treatment of choice for deep invasive sm cancer at least in patients at high risk for surgical intervention, which would avoid the risk of a surgical procedure and would improve the patient’s quality of life.

References

  1. T. Yokota, K. Sugihara, and S. Yoshida, “Endoscopic mucosal resection for colorectal neoplastic lesions,” Diseases of the Colon and Rectum, vol. 37, no. 11, pp. 1108–1111, 1994. View at: Publisher Site | Google Scholar
  2. N. A. Ahmad, M. L. Kochman, W. B. Long, E. E. Furth, and G. G. Ginsberg, “Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases,” Gastrointestinal Endoscopy, vol. 55, no. 3, pp. 390–396, 2002. View at: Publisher Site | Google Scholar
  3. R. M. Soetikno, T. Gotoda, Y. Nakanishi, and N. Soehendra, “Endoscopic mucosal resection,” Gastrointestinal Endoscopy, vol. 57, no. 4, pp. 567–579, 2003. View at: Publisher Site | Google Scholar
  4. S. Tanaka, K. Haruma, S. Oka et al., “Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm,” Gastrointestinal Endoscopy, vol. 54, no. 1, pp. 62–66, 2001. View at: Publisher Site | Google Scholar
  5. Y. Saito, T. Fujii, H. Kondo et al., “Endoscopic treatment for laterally spreading tumors in the colon,” Endoscopy, vol. 33, no. 8, pp. 682–686, 2001. View at: Publisher Site | Google Scholar
  6. R. M. Walsh, F. W. Ackroyd, and P. C. Shellito, “Endoscopic resection of large sessile colorectal polyps,” Gastrointestinal Endoscopy, vol. 38, no. 3, pp. 303–309, 1992. View at: Google Scholar
  7. Y. Saito, T. Uraoka, T. Matsuda et al., “Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections,” Gastrointestinal Endoscopy, vol. 66, no. 5, pp. 966–973, 2007. View at: Publisher Site | Google Scholar
  8. Y. Tamegai, Y. Saito, N. Masaki et al., “Endoscopic submucosal dissection: a safe technique for colorectal tumors,” Endoscopy, vol. 39, no. 5, pp. 418–422, 2007. View at: Publisher Site | Google Scholar
  9. Y. Saito, F. Emura, T. Matsuda et al., “A new sinker-assisted endoscopic submucosal dissection for colorectal cancer,” Gastrointestinal Endoscopy, vol. 62, no. 2, pp. 297–301, 2005. View at: Publisher Site | Google Scholar
  10. M. Fujishiro, N. Yahagi, M. Nakamura et al., “Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar,” Gastrointestinal Endoscopy, vol. 63, no. 2, pp. 243–249, 2006. View at: Publisher Site | Google Scholar
  11. T. Matsuda, T. Fujii, Y. Saito et al., “Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms,” American Journal of Gastroenterology, vol. 103, no. 11, pp. 2700–2706, 2008. View at: Publisher Site | Google Scholar
  12. Y. Saito, T. Uraoka, T. Matsuda et al., “A pilot study to assess the safety and efficacy of carbon dioxide insufflation during colorectal endoscopic submucosal dissection with the patient under conscious sedation,” Gastrointestinal Endoscopy, vol. 65, no. 3, pp. 537–542, 2007. View at: Publisher Site | Google Scholar
  13. H. Yamamoto, H. Kawata, K. Sunada et al., “Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate,” Gastrointestinal Endoscopy, vol. 56, no. 4, pp. 507–512, 2002. View at: Google Scholar
  14. H. Yamamoto, H. Kawata, K. Sunada et al., “Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood,” Endoscopy, vol. 35, no. 8, pp. 690–694, 2003. View at: Publisher Site | Google Scholar
  15. T. Uraoka, T. Fujii, Y. Saito et al., “Effectiveness of glycerol as a submucosal injection for EMR,” Gastrointestinal Endoscopy, vol. 61, no. 6, pp. 736–740, 2005. View at: Publisher Site | Google Scholar
  16. “The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon,” Gastrointestinal Endoscopy, vol. 58, supplement 6, pp. S3–S43, 2003. View at: Publisher Site | Google Scholar
  17. W. A. Bemelman, “Minimally invasive surgery for early lower GI cancer,” Best Practice and Research: Clinical Gastroenterology, vol. 19, no. 6, pp. 993–1005, 2005. View at: Publisher Site | Google Scholar
  18. T. Uraoka, Y. Saito, T. Matsuda et al., “Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum,” Gut, vol. 55, no. 11, pp. 1592–1597, 2006. View at: Publisher Site | Google Scholar
  19. Y. Sano, K. I. Fu, Y. Saito et al., “A newly developed bipolar-current needle-knife for endoscopic submucosal dissection of large colorectal tumors,” Endoscopy, vol. 83, supplement 2, p. E95, 2006. View at: Google Scholar

Copyright © 2009 Sergio A. Con et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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