Single center preliminary experience with endoscopic submucosal dissection for early gastrointestinal cancers

INTRODUCTION: ESD is a new and more radical treatment for early GI cancers providing high rates of “en bloc” resection compared with EMR. In contrast to Japan, the treatment of these tumors in the West is still mainly surgical. Herein, we report our preliminary experience with the ESD technique. AIMS & METHODS: Ten patients (6 M, 4 W; mean age 70.7 yrs) underwent endoscopic resection of their early cancers from March 2007 to April 2008. Lesions were in: gastric fundus (1), body (2), antrum (2); cecal fundus (1), transverse colon (1), left colon (2), rectum (1). The mean size was 21 mm. Biopsies revealed: HGD in the gastric tumors; focal HGD and LGD in the colorectal tumors. ESD was planned in OT under general anaesthesia, with back-up surgery in the event of complications. Indigo carmine (0.2%) and magnification (160x) defined the borders and the pit-pattern of the lesions. Only in the stomach, marking spots were made by needle- or hook-knife. NS plus adrenaline and IC was mainly used as injection fluid. An addition of hyaluronic acid (0.2%) was needed especially in the colon. After injection, a circumferential incision, 5 mm away from the margins of the lesion, was performed. The exposed SM layer was then dissected by It-knife using a lateral movement and sometimes in retrovision. In case of failure of “en bloc” removal, the final excision was achieved in few pieces with a polypectomy snare. Once retrieved, the specimen was fixed orientated on a board and sectioned in 2-mm intervals parallel to the closest resection margin to assess both lateral and vertical margins. RESULTS: The mean operating time was 107 minutes. Curative resection was achieved in 9 of 10 cases. Seven lesions were removed “en bloc”. In 3 cases, a “piecemeal” resection was used. In 1 case, a laparoscopic appendectomy was needed for extension of the cecal polyp to the appendiceal body. Histology revealed: intramucosal ADC in the fundic EGC; HGD in the 4 body-antrum lesions; LGD with focal HGD in the 5 colorectal tumors. In all the lesions but one, the lateral and vertical margins were free of tumor. Intraoperative bleeding was arrested by It-knife or coagrasper in any case. In 1 case only, in the left colon, delayed bleeding occurred and was conservatively managed. Perforation occurred in 2 colonic ESD, but was immediately recognized and closed by clips. At a mean FU of 4 months, no recurrence was observed. CONCLUSION: In our experience, ESD has been performed successfully in the majority of cases without major complications. ESD should be considered as elective treatment for early GI cancers as long it is performed under the right indications. More experiences are needed to strengthen the performance capacity