Feasibility of endoscopic submucosal dissection for gastric and colorectal lesions: Initial experience from the Gastrocentro - Unicamp

OBJECTIVE: Endoscopic submucosal dissection is a technique developed in Japan for en bloc resection with a lower rate of recurrence. It is considered technically difficult and performed only in specialized centers. This study sought to report the initial experience from the Gastrocentro - Campinas State University for the treatment of gastric and colorectal lesions by endoscopic submucosal dissection. MATERIALS AND METHODS: The guidelines of the Japanese Association of Gastric Cancer were used as evaluative criteria. For colorectal lesions, the recommended standards proposed by Uraoka et al. and Saito et al. were employed. The practicability of the method, the development of complications and histological analysis of the specimens were evaluated. RESULTS: Sixteen patients underwent endoscopic submucosal dissection from June 2010 to April 2011; nine patients were treated for gastric lesions, and seven were treated for colorectal lesions. The average diameter of the gastric lesions was 28.6 mm, and the duration of resection was 103 min without complications. All lesions presented lesion-free margins. Of the seven colorectal tumors, four were located in the rectum and three were located in the colon. The average size was 26 mm, and the average procedure time was 163 min. Two complications occurred during the rectal resection procedures: perforation, which was treated with an endoscopic clip, and controlled bleeding. One of the lesions presented a compromised lateral margin without relapse after 90 days. Depth margins were all free of lesions. CONCLUSION: Endoscopic submucosal dissection at our institution achieved high success rates, with few complications in preliminary procedures. The procedure also made appropriate lesion staging possible.

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas / Mucosectomia em lesões do cólon e reto: procedimento seguro e eficaz mesmo em pacientes com lesões maiores que 2 cm e em carcinomas

CONTEXT: Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. OBJECTIVES: To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. METHODS: A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique. Complications and recurrence were analyzed. Patients were followed up for 18 months. RESULTS: There were 83 (48.2 percent) superficial lesions, 57 (33.1 percent) depressed lesions, 44 (25.6 percent) laterally spreading tumors, and 45 (26.2 percent) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0 percent) lesions were located in the rectum, 68 (39.5 percent) in the left colon, and 80 (46.5 percent) in the right colon (transverse, ascending, and cecum). There were 167 (97.1 percent) neoplasms: 142 (82.5 percent) adenomatous lesions, 24 (14.0 percent) intramucosal carcinomas, and 1 (0.6 percent) invasive carcinoma. En bloc resection was performed in 158 (91.9 percent) cases and piecemeal resection in 14 (8.1 percent). Bleeding occurred in 5 (2.9 percent) cases. Recurrence was observed in 4.1 percent (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). CONCLUSIONS: Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.

CONTEXTO: A mucosectomia endoscópica é uma técnica minimamente invasiva para o tratamento de neoplasias de cólon e reto, inclusive carcinomas precoces, de diferentes tamanhos e aspectos morfológicos. OBJETIVO: Avaliar a segurança, a eficácia, os resultados e a recurrência das lesões após mucosectomia. MÉTODOS: Entre maio de 2003 e maio de 2009 um total de 172 lesões em 156 pacientes foi incluído no estudo. Todas as lesões tinham padrão de criptas sugestivo de neoplasias (III-V), segundo a classificação de Kudo, com o diagnóstico feito por colonoscópios com magnificação de imagens e índigo-carmin. As lesões foram avaliadas quanto à macroscopia, tamanho, localização e histopatologia. Lesões com até 20 mm foram removidas em bloco e as maiores que 20 mm pela técnica de piecemeal. Complicações e recurrência foram analisadas. O seguimento foi de 18 meses. RESULTADOS: Este estudo identificou 83 (48,2 por cento) lesões superficiais, sendo 57 (33,1 por cento) deprimidas, além de 44 (25,6 por cento) lesões de espraiamento lateral e 45 (26,2 por cento) protrusas. O tamanho médio foi de 11,5 ± 9,6 mm (2-60 mm) e a idade média de 61,6 ± 12,5 anos (34-93 anos). No reto estavam 24 (14 por cento) lesões, 68 (39,5 por cento) no cólon esquerdo e 80 (46,5 por cento) no cólon direito (transverso, ascendente e ceco). Foram 167 (97,1 por cento) neoplasias, sendo 142 (82,5 por cento) lesões adenomatosas, 24 (14,0 por cento) carcinomas intramucosos e 1 (0,6 por cento) carcinoma invasivo. Foram tratadas em bloco 158 (91,9 por cento) lesões e 14 (8,1 por cento), por piecemeal. Houve cinco casos (2,9 por cento) de sangramento. A recurrência foi de 4,1 por cento (5/122) e associada a lesões maiores que 20 mm (P<0,01), à técnica piecemeal (P<0,01), à neoplasia avançada (P = 0,01) e ao carcinoma quando comparado ao adenoma (P = 0,04). CONCLUSÕES: A mucosectomia endoscópica de lesões colorretais é procedimento seguro, eficaz, com baixo índice de complicações e recidiva local. A recidiva de lesão é associada a lesões maiores que 20 mm e aos carcinomas.

TRREMS procedure (transanal repair of rectocele and rectal mucosectomy with one circular stapler): a prospective multicenter trial / Procedimento TRREMS (reparo transanal de retocele e mucosectomia retal com um grampeador circular): estudo multicêntrico prospectivo

CONTEXT: Since anorectocele is usually associated with mucosa prolapse and/or rectal intussusceptions, it was developed a stapled surgical technique using one circular stapler. OBJECTIVE: To report the results of Transanal Repair of Rectocele and Rectal Mucosectomy with one Circular Stapler (TRREMS procedure) in the treatment of anorectocele with mucosa prolapse in a prospective multicenter trial. METHODS: It was conducted by 14 surgeons and included 75 female patients, mean aged 49.6 years, with symptoms of obstructed defecation due to grade 2 (26.7 percent) and grade 3 (73.3 percent) anorectocele associated with mucosa prolapse and/or rectal intussusception (52.0 percent) and an average validated Wexner constipation score of 16. All patients were evaluated by a proctological examination, cinedefecography, anal manometry and colonic transit time. The TRREMS procedure consists of the manual removal of the rectocele wall with circumferential rectal mucosectomy performed with a circular stapler. The mean follow-up time was 21 months. RESULTS: All patients presented obstructed defecation and they persisted with symptoms despite conservative treatment. The mean operative time was 42 minutes. In 13 (17.3 percent) patients, bleeding from the stapled line required hemostatic suture. Stapling was incomplete in 2 (2.6 percent). Forty-nine patients (65.3 percent) required 1 hospitalization day, the remainder (34.7 percent) 2 days. Postoperatively, 3 (4.0 percent) patients complained of persistent rectal pain and 7 (9.3 percent) developed stricture on the stapled suture subsequently treated by stricturectomy under anesthesia (n = 1), endoscopic stricturectomy with hot biopsy forceps (n = 3) and digital dilatation (n = 3). Postoperative cinedefecography showed residual grade I anorectoceles in 8 (10.6 percent). The mean Wexner constipation score decreased significantly from 16 to 4 (0-4: n = 68) (6: n = 6) (7: n = 1) (P<0.0001). CONCLUSION: Current trial results suggest that TRREMS procedure is a safe and effective technique for the treatment of anorectocele associated with mucosa prolapse. The stapling technique is low-cost as requires the use of a single circular stapler.

CONTEXTO: Como a anoretocele está sempre associada a prolapso mucoso e/ou intussuscepção retal, foi desenvolvida uma técnica cirúrgica grampeada, utilizando somente um grampeador mecânico. OBJETIVO: Demonstrar os resultados do estudo multicêntrico que realizou o tratamento cirúrgico de pacientes com anorretocele associado a prolapso mucoso, utilizando o reparo transanal da retocele e mucosectomia com grampeador circular mecânico. MÉTODO: Foram incluídos 75 pacientes, média de idade 49,6 anos, com sintomas de evacuação obstruída, apresentando escore médio de constipação de Wexner de 16 e diagnóstico de anorretocele grau II (26.7 por cento), grau III (73,3 por cento) associado a prolapso mucoso e intussuscepção (52 por cento). Todos foram avaliados com exame proctológico, defecografia, manometria anorretal e tempo de trânsito colônico. O procedimento cirúrgico foi realizado por 14 cirurgiões e consiste na remoção manual da parede do reto no local da retocele e mucosectomia circunferencial com um grampeador circular mecânico. O seguimento médio foi de 21 meses. RESULTADOS: Os pacientes apresentavam sintomas de evacuação obstruída, mesmo após tratamento clinico. O tempo operatório médio foi de 42 minutos. Houve sangramento transanal na linha de sutura em 13 (17,3 por cento) pacientes, sutura grampeada incompleta em 2 (2,6 por cento) e dor retal persistente em 3 (4,0 por cento). O tempo médio de internação hospitalar foi de 1 dia em 49 (65,3 por cento) e 2 dias em 34,7 por cento. Ocorreu redução na linha de sutura em 7 (9,3 por cento), sendo necessário estricturotomia cirúrgica sob anestesia (n = 1), utilizando "hot biopsy" (n = 3) e dilatação anal (3). Defecografia no pós-operatório demonstrou anorretocele residual grau I em 8 (10.6 por cento). O escore de constipação de Wexner reduziu 16 para 4 (0-4: n = 68) (6: n = 6) (7: n = 1) (P<0.0001). CONCLUSÃO: O resultado do estudo multicêntrico demonstrou que a técnica cirúrgica apresentada é segura e efetiva para tratamento da anorretocele associada a prolapso mucoso. Apresenta baixo custo pois utiliza um grampeador circular mecânico.