Original article
Clinical endoscopy
Endoscopic submucosal dissection for treatment of rectal carcinoid tumors

Presented at Digestive Disease Week, May 30-June 4, 2009, Chicago, Illinois
https://doi.org/10.1016/j.gie.2010.01.040Get rights and content

Background

Conventional EMR has been the endoscopic treatment of choice for rectal carcinoid tumors. However, histologically complete resection often cannot be achieved because the carcinoid tumors are located mainly in the submucosal layer. Endoscopic submucosal dissection (ESD), a new method for large colorectal neoplasm resection, may overcome this problem.

Objective

To compare ESD with EMR for the endoscopic treatment of rectal carcinoid tumors.

Design

A prospective case series with comparison to retrospective controls.

Setting

Tertiary-care center.

Patients

From January 2007 to January 2009 we prospectively enrolled consecutive patients with rectal carcinoid tumors less than 16 mm in diameter and with no regional lymph node enlargement shown by CT or EUS. For comparison, we retrospectively randomly selected patients who had undergone EMR for treatment of rectal carcinoid tumors between March 2000 and December 2006.

Intervention

We performed ESD of rectal carcinoid tumors in prospectively enrolled patients.

Main Outcome Measurements

Rate of en bloc resection, rate of histologically complete resection, incidence of complications, and length of procedures.

Results

The ESD group contained 31 patients (18 male, 13 female; age range 34-65 years), and the EMR group contained 62 patients (42 male, 20 female; age range 22-77 years). Both groups had similar mean rectal carcinoid tumor diameters (ESD 6.8 ± 2.4 mm, EMR 7.3 ± 2.2 mm; P = .106). Resection time was longer in the ESD group than in the EMR group (11.4 ± 3.7 minutes vs 4.2 ± 3.2 minutes, P < .001). The en bloc resection rate was 100% (31 of 31) in the ESD group and 95.2% (59 of 62) in the EMR group (P = .213). The histologically complete resection rate was 90.3% (28 of 31) in the ESD group and 71.0% (44 of 62) in the EMR group (P = .035). Suspected perforation occurred in 1 ESD patient (3.2%) and in 1 EMR patient (1.6%), and both patients were successfully managed by conservative measures. Immediate bleeding occurred in 1 ESD patient (3.2%) and in 4 EMR patients (6.5%); all instances of bleeding were controlled endoscopically.

Limitations

Retrospective control study and limited experience at a single center.

Conclusion

Compared with EMR, ESD resulted in a higher histologically complete resection rate, had a similar complication rate, and took slightly longer to perform. Given the advantages of complete resection, these findings indicate that ESD may be considered for treatment of rectal carcinoid tumors.

Section snippets

Patients

The primary interest of this study was to determine the histologically complete resection rate. The study was designed to have 80% power to detect an absolute difference of 30% in the histologically complete resection rate, with a 2-sided alpha level of 0.05. The sample size required to detect this difference was 31 patients per group. We prospectively performed ESD in 31 consecutive patients with rectal carcinoid tumors from January 2007 to January 2009 at the Asan Medical Center, Seoul,

Patient characteristics

The ESD and EMR groups were similar in terms of sex and age distribution. The endoscopically estimated diameter of rectal carcinoid tumors was 5 to 13 mm in both groups (P = .106). The histologically measured sizes of the resected specimens were similar to the endoscopically estimated diameters. The baseline characteristics of the two groups are shown in Table 1.

Endoscopic and histologically complete resection

Endoscopic complete resection was achieved in 31 of 31 (100%) ESD patients and in 59 of 62 (95%) EMR patients (P = .213) (Fig. 4).

Discussion

This prospective trial found that ESD resulted in histologically complete resection in 90% of patients with rectal carcinoid tumors, thus higher than the 71% rate achieved by using EMR. Furthermore, the 90% histologically complete resection rate by ESD in the present study is higher than the 38% to 86% rates reported by others using various conventional endoscopic resection methods, including cap-assisted EMR and EMR with a ligation device.12, 13, 14, 25, 26

The higher histologically complete

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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