Pushing the Envelope in Endoscopic Submucosal Dissection: Is It Feasible and Safe In Scarred Lesions?

BACKGROUND Endoscopic submucosal dissection is an established advanced polypectomy technique to manage large colorectal polyps. OBJECTIVE The purpose of this study was to evaluate patients who had endoscopic submucosal dissection in the setting of significant scarring attributed to a previous intervention to determine whether this is safe and feasible. DESIGN The study used a prospectively maintained database. SETTINGS A scarred lesion was defined as a nonlifting polyp with a history of previous attempted removal with endoscopic mucosal resection, snare, or biopsy where there was no suspicion of malignancy. PATIENTS All consecutive patients in the previous 14 months were included. INTERVENTION Endoscopic submucosal dissection was the study intervention. MAIN OUTCOME MEASURES Thirty-day morbidity and mortality, readmission, length of stay, and recurrence were measured. RESULTS Ninety-one patients had endoscopic submucosal dissection over a 14-month period with a median polyp size of 31.5 mm (range, 20-45 mm). Eleven patients (12%) were confirmed as having significant scar. There were significantly more previous endoscopic mucosal resections in the scarred group (scarred: 63.6% vs nonscarred: 2.5%; p < 0.001). Significantly more of the scarred patients had their endoscopic submucosal dissection in the operating room versus the endoscopy suite (scarred: 82.0% vs nonscarred: 17.5%; p < 0.001). The 30-day morbidity rate was 18.7%. There were no mortalities. There was no difference in 30-day morbidity between scarred and nonscarred lesions (scarred: 9% vs nonscarred: 20%; p = 0.4). There were more day-case procedures in the nonscarred group (nonscarred: 93.7% vs scarred: 36.4%; p < 0.001). There was no malignancy on final pathology in the scarred group. There was no difference in readmission rate between the scarred and nonscarred lesions. The overall follow-up colonoscopy rate was 53%, and there were no polyp recurrences identified. LIMITATIONS The study was limited by its small sample size, single institute, surgeon experience, and short follow-up. CONCLUSIONS Not only is endoscopic submucosal dissection in patients who have scarred lesions technically feasible and safe, it avoids a bowel resection in the majority of patients who have exhausted other advanced endoscopy techniques. See Video Abstract at http://links.lww.com/DCR/B427. EMPUJAR EL SOBRE EN LA DISECCIN ENDOSCPICA SUBMUCOSA ES FACTIBLE Y SEGURO EN LESIONES CICATRIZADAS ANTECEDENTES:La diseccion endoscopica submucosa es una tecnica de polipectomia avanzada establecida para tratar polipos colorrectales grandes.OBJETIVO:Evaluar a pacientes que se sometieron a diseccion submucosa endoscopica en el contexto de cicatrices significativas debido a una intervencion previa para determinar si esto es seguro y factible.DISENO:Base de datos mantenida prospectivamente.AJUSTE:Una lesion cicatrizada se definio como un polipo que no se levanta con antecedentes de intento de extirpacion previa con reseccion endoscopica de la mucosa, lazo o biopsia, donde no habia sospecha de malignidad.PACIENTES:Todos los pacientes consecutivos en los ultimos 14 meses.INTERVENCION:Diseccion submucosa endoscopica.MEDIDAS DE RESULTADOS PRINCIPALES:Morbilidad y mortalidad a 30 dias, reingreso, duracion de la estadia, recurrencia.RESULTADOS:Noventa y un pacientes tuvieron diseccion submucosa endoscopica durante un periodo de 14 meses con tamano de polipo mediana de 31,5 mm (rango, 20 - 45 mm). Se confirmo que once pacientes (12%) tenian una cicatriz significativa. Hubo significativamente mas resecciones de mucosa endoscopica previas en el grupo con cicatrices (con cicatrices: 63,6% vs. sin cicatrices: 2,5%, p <0,001). Significativamente mas de los pacientes con cicatrices tuvieron su diseccion submucosa endoscopica en el quirofano en comparacion con la sala de endoscopia (con cicatrices: 82% vs. sin cicatrices: 17.5%, p <0.001). La tasa de morbilidad a 30 dias fue del 18,7%. No hubo muertes. No hubo diferencia en la morbilidad a 30 dias entre las lesiones cicatrizadas y no cicatrizadas (cicatrizadas: 9% frente a no cicatrizadas: 20%, p = 0,4). Hubo mas procedimientos ambulatorios en el grupo sin cicatrices (sin cicatrices: 93,7% frente a cicatrices: 36,36%, p <0,001). No hubo malignidad en la patologia final en el grupo con cicatrices. No hubo diferencia en la tasa de reingreso entre las lesiones cicatrizadas y no cicatrizadas. La tasa general de colonoscopia de seguimiento fue del 53% y no se identificaron recurrencias de polipos.LIMITACIONES:Tamano de muestra pequeno, experiencia de un solo instituto y cirujanos y seguimiento corto.CONCLUSION:La diseccion endoscopica submucosa en pacientes con lesiones cicatrizadas no solo es tecnicamente factible y segura, sino que evita una reseccion intestinal en la mayoria de los pacientes que han agotado otras tecnicas endoscopicas avanzadas. Consulte Video Resumen en http://links.lww.com/DCR/B427.