Endoscopic management of large laterally spreading colorectal tumors (LSTs): a comparative study of techniques and outcomes
DOI:
https://doi.org/10.14739/2310-1210.2025.3.328192Keywords:
colonoscopy, laterally spreading tumor, colorectal neoplasms, endoscopic submucosal dissection, recurrenceAbstract
Laterally spreading colorectal tumors (LSTs) are associated with a risk of high-grade dysplasia and potential malignant transformation. Endoscopic resection is the standard of care for non-invasive LSTs, with the choice of technique guided by lesion size, morphology, and recurrence risk. The most commonly employed methods include endoscopic mucosal resection (EMR), piecemeal EMR (pEMR), endoscopic submucosal dissection (ESD), and hybrid ESD. Comparative data on the safety and efficacy of these techniques remain limited.
Aim. To compare EMR, pEMR, ESD, and hybrid ESD with respect to complication rates (bleeding, perforation), recurrence, and influencing factors.
Materials and methods. In this single-center, retrospective-prospective study, 100 adult patients with non-invasive LSTs larger than 20 mm were enrolled. Lesions were assessed by expert endoscopists using image-enhanced endoscopy and standardized classifications to analyze surface pit patterns and vascular architecture. Endoscopic resection was then performed by EMR, pEMR, ESD, or hybrid ESD according to lesion size and morphology. Statistical analyses were conducted in “Statistica 13” using binary logistic regression (odds ratios with 95 % confidence intervals), Pearson’s correlation coefficient, and significance set at p < 0.05.
Results. The mean patient age was 64.59 ± 10.89 years. LSTs were granular in 66 % of cases and non-granular in 34 %. Mean lesion size was greatest for ESD (46.6 ± 16.18 mm) and smallest for EMR (21.07 ± 2.49 mm); pEMR and hybrid ESD averaged 33.47 ± 15.20 mm and 38.64 ± 13.62 mm, respectively. Intraoperative perforation occurred in 20 % of ESD cases versus 0 % with EMR / pEMR (OR 0.065, p = 0.021, 95 % CI: 0.0034–1.2500 / OR 0.051, p = 0.008, 95 % CI: 0.0027–0.9700) and 9.09 % with hybrid ESD. Intraoperative bleeding was significantly more frequent during hybrid ESD (36.36 %) compared to pEMR (2.78 %; OR 0.12, p = 0.008, 95 % CI: 0.021 0.690), en bloc EMR (3.57 %; OR 0.091, p = 0.008, 95 % CI: 0.012–0.680), and ESD (4.00 %; OR 0.10, p = 0.013, 95 % CI: 0.014–0.770). Hybrid ESD had a higher recurrence rate (27.27 %) than EMR (0.00 %; OR 0.043, p = 0.007, 95 % CI: 0.002–0.910) and ESD (4.00 %; OR 0.15, p = 0.047, 95 % CI: 0.019–1.170); pEMR recurrence was 11.11 %. A weak positive correlation was observed between recurrence and tubulovillous adenoma morphology (r = 0.233, p = 0.02) and rectal location (r = 0.281, p = 0.005). All complications and recurrences were successfully managed endoscopically.
Conclusions. EMR, pEMR, and ESD are safe and effective for resecting large LSTs, though ESD has a higher risk of intraoperative perforation. Given the elevated rates of recurrence and intraoperative bleeding with hybrid ESD, further investigation of this technique is warranted. Recurrences are more frequent following resection of tubulovillous adenomas and when lesions are located in the rectum.
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