Vanella Giuseppe, Coluccio Chiara, Antonelli Giulio, Angeletti Stefano, Micheli Federica, Barbato Antonio, De Rossi Gaia, Marchetti Alessandro, Mereu Elena, Pepe Paola, Corleto Vito Domenico, D'Ambra Giancarlo, Ruggeri Maurizio, Di Giulio Emilio
Endoscopy Unit, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy.
Endosc Int Open. 2020 Oct;8(10):E1252-E1263. doi: 10.1055/a-1220-6261. Epub 2020 Sep 22.
Outcomes of endoscopic assessment and management of large colorectal (CR) non-pedunculated lesions (LNPLs) are still under evaluation, especially in Western settings. We analyzed the clinical impact of changes in LNPL management over the last decade in a European center. All consecutive LNPLs ≥ 20 mm endoscopically assessed (2008-2019) were retrospectively included. Lesion, patient, and resection characteristics were compared among clinically relevant subgroups. Multivariate logistic regression (for predictors of submucosal invasion [SMI] and recurrence), Kaplan-Meier curves and ROC curves (for temporal cut-offs in trends analyses) were used. A total of 395 LNPLs were included (30 mm [range 20-40]; SMI = 9.6 %; primary endoscopic resection [ER] = 88.4 %). Pseudo-depression and JNET classification independently predicted SMI beyond single morphologies/location. After complete ER, involvement of ileocecal valve/dentate line, piece-meal resection and high-grade dysplasia independently predicted recurrence. Rates of 5-year recurrence-free, surgery-free and cancer-free survival were 77.5 %, 98.6 % and 100 %, respectively, with 93.8 % recurrences endoscopically managed and no death attributable to ER or CR cancer (versus 3.4 % primary surgery mortality). ROC curves identified the period ≥ 2015 (following Endoscopic Submucosal Dissection [ESD] introduction and education on pre-resective lesion assessment) as associated with improved lesions' characterization, increased en-bloc resection of SMI lesions (87.5 % vs 37.5 %; p = 0.0455), reduced primary surgery (7.5 % vs 16.7 %; p = 0.0072), surgical referral of benign lesions (5.1 % vs 14.8 %; p = 0.0019), and recurrences. ESD introduction and educational interventions allowed ER of more complex lesions, offset by increased complementary surgery for complications or intrinsic histological risk. Nevertheless, overall, they have reduced surgery demand and increased appropriateness and safety of LNPL management in our center.
大肠（CR）大的无蒂病变（LNPLs）的内镜评估和处理结果仍在评估中，尤其是在西方环境中。我们分析了欧洲一家中心在过去十年中LNPLs处理变化的临床影响。回顾性纳入了所有连续的经内镜评估的≥20mm的LNPLs（2008 - 2019年）。比较了临床相关亚组之间的病变、患者和切除特征。使用多变量逻辑回归（用于预测黏膜下浸润[SMI]和复发）、Kaplan - Meier曲线和ROC曲线（用于趋势分析中的时间截断点）。共纳入395个LNPLs（中位大小30mm[范围20 - 40]；SMI = 9.6%；初次内镜切除[ER] = 88.4%）。假性凹陷和JNET分类独立预测了单一形态/位置之外的SMI。完全ER后，回盲瓣/齿状线受累、分片切除和高级别异型增生独立预测复发。5年无复发、无手术和无癌生存率分别为77.5%、98.6%和100%，93.8%的复发通过内镜处理，且无因ER或CR癌导致的死亡（相比之下，初次手术死亡率为3.4%）。ROC曲线确定≥2015年期间（在内镜黏膜下剥离术[ESD]引入以及对术前病变评估进行教育之后）与病变特征改善、SMI病变整块切除增加（87.5%对37.5%；p = 0.0455）、初次手术减少（7.5%对16.7%；p = 0.0072）、良性病变的手术转诊减少（5.1%对14.8%；p = 0.0019）以及复发减少相关。ESD的引入和教育干预使得更复杂的病变能够进行ER，但因并发症或内在组织学风险导致的补充手术增加而有所抵消。然而，总体而言，它们减少了手术需求，并提高了我们中心LNPLs处理的适宜性和安全性。
