CHICAGO—For managing colorectal lesions not sufficiently treated with a first attempt, endoscopic submucosal dissection achieved high rates of en bloc and R0 resection with low rates of local recurrence and perforation in a largely North American patient population.
“Salvage ESD is highly effective for the treatment of previously attempted colorectal lesions (PACL),” said Suchapa Arayakarnkul, MD, a post-doctoral research fellow at the Johns Hopkins Hospital, in Baltimore. “When ESD is performed by experts, adverse events are uncommon and most can be managed endoscopically. The results of our study support the role of ESD for PACL in the Western setting.”
Presenting data on her team’s success with this approach at Digestive Disease Week 2023, Dr. Arayakarnkul reported a 90% rate of en bloc resection, 5% rate of local recurrence and 5% rate of intraprocedural perforation (conservatively managed in 4.5%) for patients who underwent ESD as treatment for PACL (abstract 591).
Although endoscopic resection is highly effective for removing large colorectal neoplasia, recurrent or residual lesions are common and pose a clinical challenge, Dr. Arayakarnkul said. Salvage ESD can achieve en bloc resection for treating often technically challenging PACL, with much lower local recurrence rates than have been reported (8%-14%) for endoscopic mucosal resection (EMR) (Am J Gastroenterol 2021;116[5]:958-966).
Examining Salvage In Western Settings
However, most studies of salvage ESD have been small, retrospective and in Asian populations, and these studies have shown varying outcomes for efficacy and safety, Dr. Arayakarnkul said. To evaluate the efficacy and outcomes of salvage ESD for PACL performed in Western practices, she and her co-investigators evaluated outcomes in 360 consecutive patients treated with ESD for PACL at 19 tertiary care centers—15 of which were in North America—from May 2014 to October 2022.
For treatment of the index lesion at baseline, 64% of patients had EMR, 31% had snare polypectomy, 4% had surgery and less than 1% had ESD. The median lesion size was 40 mm. Most lesions were located in the rectum (46%) or ascending colon (24%). Adenomas were the most common pre-ESD lesion (68%), while the rest were mostly cancers, which, notably, were invasive in 1% of cases. Submucosal fibrosis was considered severe (F2) in 44% of patients.
The mean ESD procedure time was 95 minutes. For 81% of patients, ESD was performed in an outpatient setting. The remaining patients were admitted for observation (median length of stay, one day).
With ESD, en bloc resection (Figure) was achieved in 89.7% of cases and R0 resection was achieved in 81.1%. The procedure was considered curative in 79.4% of patients. Post-ESD histology showed adenomas in 66%, high-grade/intramucosal cancer in 21%, invasive cancer in 8% and other results in 4%, Dr. Arayakarnkul reported.
Of the 238 patients with longer follow-up, 13 (5.5%) had local recurrences. Histopathology showed adenomas in 11 (3.1%), with one patient having a high-grade cancer (0.3%) and another having invasive cancer (0.3%). “All local recurrences were managed with repeat endoscopy,” she said.
Intraprocedural perforation occurred in 17 of the 360 patients (4.7%), with 16 managed intraprocedurally and one surgically. Three patients (0.8%) experienced intraprocedural severe bleeding, and all were managed intraprocedurally. Other adverse events included delayed perforation (0.6%), delayed bleeding (2.0%), delayed stricture (1.7%) and post-polypectomy syndrome (0.9%), most of which responded to conservative treatment.
Goal Should Be Avoiding Need for Salvage
“This study is [a] highly relevant study, especially in the U.S. population where we frequently encounter lesions that have had prior endoscopic resection attempts,” said Phillip Ge, MD, an assistant professor of medicine at The University of Texas MD Anderson Cancer Center, in Houston. The caveat is that ESD was performed in “expert hands,” and their “promising results are challenging to reproduce.”
Dr. Ge noted that “there is a bigger underlying issue of why PACLs occur to begin with. ‘Salvage’ ESD is, by definition, an undesirable situation, especially when colorectal ESD is limited to a handful of expert centers across North America. An important takeaway message is that we need to do a better job educating our colleagues in performing high-quality endoscopic resection—whether it is ESD or EMR—so that we can reduce the incidence of PACLs and, by extension, a very challenging salvage endoscopic resection.”
—Caroline Helwick
Drs. Arayakarnkul and Ge reported no relevant financial disclosures.
This article is from the July 2023 print issue.