Joint Hospital Surgical Grandround10/2009

Lesions larger than 2cm are considered large colonic lesions

Prevalence 0.8% - 5.2%

Polyps at difficult position◦Flexure◦Behind the folds◦Next to diverticula

Adenoma-Carcinoma Sequence

Endoscopic resection applied only in lesion with no nodal metastasis.

Otherwise oncological surgical resection should be considered.

Histologically deep invasion of submucosa is associated with risk of nodal metastasis.

Cut-off limit is <1000µm (sm1) in colon.

Morphological Assessment – Paris Classification◦ In 2002, an international group of endoscopists,

surgeons and pathologits gathered in Paris to propose framework for endoscopic classification of superficial lesions of the esophagus, stomach and colon.

◦ Borrmann classification was modified Proposed in 1926, Japan For assessment of ADVANCE gastric tumors Type 1 to Type 4

Type 0 is introduced to distinguish the classification of superficial lesion.

Association of morphology to submucosal invasion

Pit Pattern – Kudo Classification

Kudo Classification

Kudo Classification

Various techniques◦ Snare resection◦ Inject-lift-cut/Strip biopsy◦ Suction cup/EMR with

ligation

EMR is group of varies techniques feasible for remove large colonic lesion.

En-bloc resection rate 63% Cure en-bloc resection rate 59% Bleeding rates 7% Perforation rate 0-2%

Limitation at 2-3cm size for enbloc resection, although size 7cm with piecemeal is possible

Persistent and recurrent rate 7-22% Still have difficulties access if in the flexure,

sigmoid, near diverticula and behind the mucosal fold

EMR seems not to be perfect to manage difficult colonic polyps, especially unexpected malignant lesions

Surgical Resection

Provide excellent oncological clearance for both benign and malignant lesions.

No limitation on site and size and shape of polyp

Various RCT study on colonic cancer showed laparoscopic colectomy is feasible, safe and effective. (Barcelona RCT, COST, COLOR, CLASICC, Taiwan trials)

Complications•4 cases of intra-abdominal abscess need CT-guided drainage, 1 patient need reoperation•2 cases of delay bleeding need surgical interventions•1 patient die with anastomotic leakage

Colonic resection is safe and effective for remove difficult colonic lesion.

Major operation risk – General anesthesia, anastomotic leakage, post-operative complications (eg. DVT, PE, Pneumonia)

Pain Hospitalization

For benign lesion, could it be less invasive?

ESD is position between treatment of EMR and laparoscopic surgery.

Enodscopic Submucosal Dissection (ESD) is a techniques develop from one of the EMR techniques, namely endoscopic resection after local injection of hypertonic saline-epinephrine (ERHSE).

ESD was propose in 2003 to name this technique.

ESD advantages over EMR1. Resected size and shape is controlled2. En bloc resection is possible even larger than

20mm3. Neoplasms with submuocosal fibrosis maybe

possible for resection.

Three STEPS1. Injecting fluid into submucosa to elevate

lesion2. Cutting surround mucosa of lesion3. Dissection the submucosa beneath the lesion

EMR and ESD is less invasive should be preferred if possible.

But there is problem with lesions of unexpected malignancy.

Principle of endoscopic treatment should be applied to lesion with no risk of nodal metastasis.

Preoperative assessment of lesion is crucial.◦ Morphological◦ Chormoendoscopy with or without magnifying

endoscopy◦ Endoscopic Ultrasounography

Both assessment and procedure depend specific instruments and trained endoscopist.

Colonic resection should be considered for lesion risk of metastasis.

Laparoscopic colectomy is well proven safe and effective.

Endoscopy assisted laparoscopic colectomy is suggested to decrease the extend of surgery.

Management of difficult colonic lesion is still debatable.

Long term outcome and Control trail are still not studied.

Endoscopic assessment and excision need specialized instrument and training which is still developing.

Good endoscopic assessment for risk of deep invasion is crucial for choosing best management.