1. Management of Difficult Colonic Lesions
Joint Hospital Surgical Grandround
10/2009

2. Challenge to Endoscopist
Lesions larger than 2cm are considered large colonic lesions
Prevalence 0.8% - 5.2%

3. Challenge to Endoscopist
Polyps at difficult position
Flexure
Behind the folds
Next to diverticula

4. Background
Adenoma-Carcinoma Sequence

5. How Do we remove it?

6. Principle of Management
Endoscopic resection applied only in lesion with no nodal metastasis.
Otherwise oncological surgical resection should be considered.

7. Pre-operative Assessment
Histologically deep invasion of submucosa is associated with risk of nodal metastasis.
Cut-off limit is <1000µm (sm1) in colon.

8. Pre-operative Assessment
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

9. Pre-operative Assessment
Type 0 is introduced to distinguish the classification of superficial lesion.

10. Pre-operative Assessment

11. Pre-operative Assessment
Association of morphology to submucosal invasion

12. Pre-operative Assessment

13. Pre-operative Assessment

14. Pre-operative Assessment

15. Pre-operative Assessment

16. Pre-operative Assessment

17. Pre-operative Assessment
Pit Pattern – Kudo Classification

18. Pre-operative Assessment
Kudo Classification

19. Pre-operative Assessment
Kudo Classification

20. Endoscopic Mucosal Resection

21. Endoscopic Mucosal Resection (EMR)
Various techniques
Snare resection
Inject-lift-cut/Strip biopsy
Suction cup/EMR with ligation

32. Endoscopic Mucosal Resection (EMR)
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%

33. Endoscopic Mucosal Resection (EMR)
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

34. How to get better Clearance?
Surgical Resection

35. Colonic 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)

42. 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

43. Colonic Resection
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?

44. Less is more

45. Endoscopic Submucosal Dissection (ESD)
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.

46. Endoscopic Submucosal Dissection (ESD)
ESD advantages over EMR
Resected size and shape is controlled
En bloc resection is possible even larger than 20mm
Neoplasms with submuocosal fibrosis maybe possible for resection.

47. Endoscopic Submucosal Dissection (ESD)
Three STEPS
Injecting fluid into submucosa to elevate lesion
Cutting surround mucosa of lesion
Dissection the submucosa beneath the lesion

54. Which is better Management?

55. EMR and ESD
EMR and ESD is less invasive should be preferred if possible.
But there is problem with lesions of unexpected malignancy.

56. EMR and ESD
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.

57. Colonic resection
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.

58. Conclusion 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.

59. References

60. The End