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Endoscopic treatment for early stage colorectal tumors: The comparison between EMR with small incision, simplified ESD, and ESD using the standard Flush knife and the ball tipped Flush knife

Toyonaga T. (Department of Endoscopy, Kobe University Hospital, Japan)
Man-i M. (Department of Gastroenterology, Kobe University, Japan)
Chinzei R. (Department of Gastroenterology, Kobe University, Japan)
Takada N. (Department of Surgery, Takaishi Kamo Hospital, Japan)
Iwata Y. (Department of Gastroenterology, Takaishi Kamo Hospital, Japan)
Morita Y. (Department of Gastroenterology, Kobe University, Japan)
Sanuki T. (Department of Gastroenterology, Kobe University, Japan)
Yoshida M. (Department of Gastroenterology, Kobe University, Japan)
Fujita T. (Department of Gastroenterology, Kobe University, Japan)
Kutsumi H. (Department of Gastroenterology, Kobe University, Japan)
Hayakumo T. (Department of Gastroenterology, Kobe University, Japan)
Inokuchi H. (Department of Gastroenterology, Hyogo Cancer Center, Japan)
Azuma T. (Department of Gastroenterology, Kobe University, Japan)

BACKGROUND: Early stage colorectal tumors can be removed by endoscopic mucosal resection but larger such tumors (>20mm) may require piecemeal resection. Endoscopic submucosal dissection (ESD) using newly developed endoknives has enabled en-block resection of lesions regardless of size and shape. However ESD for colorectal tumor is technically difficult. Therefore, we performed EMR with small incision (EMR with SI) for more reliable EMR, ESD with snaring (simplified ESD) and ESD using thestandard Flush knife and the novel ball tipped Flush knife (Flush knife BT) for easier and safer colorectal ESD. AIMS: The aims of our study were 1) to compare the treatment results of the following 3 methods (EMR with SI/simplified ESD/ ESD) for early stage colorectal tumors, and 2) to assess the performance of Flush knife BT in colorectal ESD. METHODS: We treated 24/44/468 colorectal tumors and examined the clinicopathological features and treatment results such as tumor size, resected specimen size, procedure time, en-bloc resection rate, complication rate. We also treated 58 colorectal tumors (LST-NG:20, LST-G:36, other:2) using standard Flush knife and 80 colorectal tumors (LST-NG:32, LSTG: 44, other:2) using Flush knife BT, and examined the clinicopathological features and treatment results mentioned above and also the procedure speed. RESULT: The median tumor size (mm) (EMR with SI/ simplified EMR/ESD) was 20/17/30 (EMR with SI vs. simplified ESD:p=n.s, simplified ESD vs. ESD:p< 0.0001). The median resected specimen size (mm) was 22.5/26 /41 (EMR with SI vs. simplified ESD: p=0.0018, simplified ESD vs. ESD: p<0.0001). The procedure time (min.) was 19/27/60 (EMR with SI vs. simplified ESD: p=n.s, simplified ESD vs. ESD: p< 0.0001) The en-block resection rate (%) was 83.3/90.9 /98.9. The complication rate (post-operative bleeding rate/perforation rate) was 0/0, 2.3/4.5, 1.5/1.5 (simplified ESD vs. ESD : p=n.s). In the treatment results of ESD for LSTs by knives, there was no difference between standard Flush knife and Flush knife BT for clinicopathological features and treatment results (procedure time, complication rate and en bloc R0 resection rate). However, procedure speed (cm2/min.) of LST-G was significantly faster in the Flush knife BT than in standard Flush knife. (standard Flush knife: 0.21 vs. Flush knife BT: 0.27, p= 0.034). CONCLUSION: EMR with small incision (EMR with SI) and ESD with snaring (simplified ESD) are good option to fill the gap between EMR and ESD in the colorectum, and also considered to become the nice training for the introduction of ESD. Flush knife BT appears to improve procedure speed compared with standard Flush knife, especially for LST-G in colorectal ESD.

Keywords: Colorectal neoplasms, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), EMR with small incision, simplified ESD, Flush knife, Flush knife BT