Sato Koichiro, Ito Sayo, Kitagawa Tomoyuki, Kato Mitsuru, Tominaga Kenji, Suzuki Takeshi, Maetani Iruru
Division of Gastroenterology and Hepatology , Department of Internal Medicine, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan,
Surg Endosc. 2014 Oct;28(10):2959-65. doi: 10.1007/s00464-014-3558-y. Epub 2014 May 23.
Endoscopic submucosal dissection (ESD) for colorectal tumors is technically difficult due to the anatomy of the large intestine, with its narrow lumen, thin walls, and redundancy. Here, we assessed factors associated with incomplete resection and difficult colorectal ESD.
Between November 2009 and April 2013, we performed ESD on 151 consecutive colorectal tumors in 147 patients. We evaluated the clinical outcomes of all cases and conducted multiple logistic regression analysis of the following factors related to incomplete resection and difficult procedure: age, gender, location (right colon, left colon or rectum), tumor size (diameter ≥40 or <40 mm), operation time, morphology [granular-type laterally spreading tumor (LST-G), non-granular-type laterally spreading tumor (LST-NG), or protruded type], fibrosis, and paradoxical movement during the procedure. A procedure that required more than 120 min was defined as a difficult colorectal ESD.
Average tumor size was 32.1 ± 10.7 mm, and the average procedure length was 71.8 ± 49.5 min. The rate of en bloc resection was 94.7%, while that of en bloc curative resection was 86.8%. Perforation occurred in 1.3% of the ESD procedures. Multivariate logistic regression analysis revealed that only severe fibrosis [odds ratio (OR) 4.51; 95% confidence interval (CI) 1.36-14.91, p = 0.014] contributed to incomplete resection and that a tumor size exceeding 40 mm (OR 5.73 [95% CI 1.66-19.74], p = 0.006), severe fibrosis (OR 23.31 [95% CI 6.59-82.54], p < 0.001), and paradoxical movement (OR 4.26 [95% CI 1.11-16.44], p = 0.035) were independent factors exacerbating the difficulty of colorectal ESD.
Severe fibrosis contributed to both incomplete resection and difficult colorectal ESD. Larger tumor size and paradoxical movement during the procedure were independent factors contributing to the difficulty of colorectal ESD. These factors might enable endoscopists to develop strategies for treating colorectal ESD.
由于大肠的解剖结构，其管腔狭窄、壁薄且冗长，因此结直肠肿瘤的内镜黏膜下剥离术（ESD）在技术上具有挑战性。在此，我们评估了与切除不完全及困难的结直肠ESD相关的因素。
2009年11月至2013年4月期间，我们对147例患者的151个连续结直肠肿瘤进行了ESD。我们评估了所有病例的临床结果，并对以下与切除不完全及手术困难相关的因素进行了多因素逻辑回归分析：年龄、性别、位置（右半结肠、左半结肠或直肠）、肿瘤大小（直径≥40或<40 mm）、手术时间、形态[颗粒型侧向扩散肿瘤（LST-G）、非颗粒型侧向扩散肿瘤（LST-NG）或隆起型]、纤维化以及手术过程中的矛盾运动。将需要超过120分钟的手术定义为困难的结直肠ESD。
平均肿瘤大小为32.1±10.7 mm，平均手术时长为71.8±49.5分钟。整块切除率为94.7%，整块根治性切除率为86.8%。ESD手术中穿孔发生率为1.3%。多因素逻辑回归分析显示，只有严重纤维化[比值比（OR）4.51；95%置信区间（CI）1.36 - 14.91，p = 0.014]导致切除不完全，且肿瘤大小超过40 mm（OR 5.73 [95% CI 1.66 - 19.74]，p = 0.006）、严重纤维化（OR 23.31 [95% CI 6.59 - 82.54]，p < 0.001）和矛盾运动（OR 4.26 [95% CI 1.11 - 16.44]，p = 0.035）是加剧结直肠ESD难度的独立因素。
严重纤维化导致切除不完全以及结直肠ESD困难。较大的肿瘤大小和手术过程中的矛盾运动是导致结直肠ESD困难的独立因素。这些因素可能使内镜医师能够制定治疗结直肠ESD的策略。
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