|Year : 2016 | Volume
| Issue : 5 | Page : 43-46
Application value of endoscopic submucosal dissection and endoscopic mucosal resection for treatment of rectal carcinoids
Xiaohuan Li1, Yongxian Gui2, Wenliang Han1, Hongjian Jiang1, Daihua Qi1, Yi Yang1
1 Department of Medical (Endoscopy), Xinxiang Central Hospital of Henan Province, Xinxiang 453000, PR China
2 Department of Oncology, Xinxiang Central Hospital of Henan Province, Xinxiang 453000, PR China
|Date of Web Publication||7-Oct-2016|
Department of Medical (Endoscopy), Xinxiang Central Hospital of Henan Province, Xinxiang 453000
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study is to explore the clinical effect and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for treatment of rectal carcinoids.
Methods: A retrospective analysis was conducted on 42 patients with rectal carcinoids who were hospitalized and subjected to surgical treatment in our hospital from January 2010 to November 2015. The patients were categorized into two groups based on treatment received: ESD (n = 22) and EMR (n = 20). The patients were analyzed and compared to determine differences in lesion size, operation time, histopathologically curative resection rate, intraoperative complications, complete lesion resection rate, and postoperative recurrence rate between the two groups.
Results: Operation time (25.2 ± 20.1 min) and wound surface diameter (36.2 ± 10.1 mm) were significantly higher in the ESD group than those in the EMR group (12.6 ± 8.4 min and 18.6 ± 5.9 mm, respectively) (P < 0.05). The differences in complete lesion and histopathologically curative resection rates between the two groups were not statistically significant (P > 0.05). Delayed hemorrhage was the primary postoperative complication in both groups. Postoperative follow-up was performed for 3–71 months, and the median follow-up time was 45 months. Recurrence was noted 32 months after surgery in one patient in the EMR group (4.5%), whereas recurrence was not detected in the ESD group.
Conclusion: ESD and EMR are safe and effective methods for treatment of rectal carcinoids. Moreover, ESD had less risk of recurrence, more complete resection rate which could provide more information for postoperative treatment.
Keywords: Endoscopic mucosal resection, endoscopic submucosal dissection, rectal carcinoid
|How to cite this article:|
Li X, Gui Y, Han W, Jiang H, Qi D, Yang Y. Application value of endoscopic submucosal dissection and endoscopic mucosal resection for treatment of rectal carcinoids. J Can Res Ther 2016;12:43-6
|How to cite this URL:|
Li X, Gui Y, Han W, Jiang H, Qi D, Yang Y. Application value of endoscopic submucosal dissection and endoscopic mucosal resection for treatment of rectal carcinoids. J Can Res Ther [serial online] 2016 [cited 2018 Aug 16];12:43-6. Available from: http://www.cancerjournal.net/text.asp?2016/12/5/43/191628
| > Introduction|| |
Carcinoid is a neuroendocrine tumor with relatively slow growth and potential malignancy. The tumor is derived from argentaffine cells (Kulchitsky's cells) at the base of the intestinal gland tube. Carcinoid tumors are also known as argentaffine carcinoma because of their affinity to silver staining. Carcinoid is rarely observed in clinical practice, and the tumor is found in multiple sites throughout the body, particularly in the digestive tract. An epidemiologic study  reported that digestive carcinoids account for more than 50% of endocrine tumors of the digestive tract; the predilection sites include an appendix, small intestine, rectum, stomach, and colon. Rectal carcinoid is the most common carcinoid in China. Digestive carcinoids are conventionally treated through limited or radical resection. Thus far, new safe and effective methods have been developed for the treatment of digestive carcinoids because of development in endoscopic technology as well as the gradual maturity of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).
In this study, we report a retrospective study on cases of rectal carcinoids treated with EMR and ESD in our hospital in recent years. The clinical effect and safety of both treatment options are also investigated.
| > Methods|| |
A retrospective analysis was conducted on 42 patients with rectal carcinoids who were hospitalized and subjected to surgical treatment in our hospital from January 2010 to November 2015. The patients were categorized into two groups based on treatment received: ESD (n = 22) and EMR (n = 20). The following patients were included in the study: (1) pathologically or cytologically diagnosed with rectal carcinoid, (2) with available postoperative follow-up data, (3) with complete clinical pathology data, and (4) advised to undergo ESD or EMR for treatment. Meanwhile, the following patients were excluded: (1) with rectal tumor of another pathological type, (2) without follow-up data, (3) with incomplete clinical pathology data, (4) treated with other methods, (5) with condition complicated by other malignant tumors, and (6) with anorectal malformation or past surgical history. Given the inclusion and exclusion criteria, 42 patients were included in the study. The clinical baseline conditions of patients in both groups are shown in [Table 1].
|Table 1: Comparison of the clinical baseline conditions of patients in both groups|
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Patients in both groups were given oral cathartics preoperatively to clean the intestinal tract. Blood coagulation function and routine tests, abdominal-B ultrasonography, echocardiography, and serum carcinoembryonic antigen analysis were performed. Preoperative endoscopic ultrasonography was also conducted to identify whether lesions are limited within the mucous membrane or reached the submucous membrane as well as determine whether the diameters of the lesions are <2 cm. Moreover, pelvic and abdominal computed tomography or magnetic resonance imaging was conducted to exclude distant metastasis.
Endoscopic submucosal dissection
A transparent cap was added to the endoscopic head, and a circumferential electrical coagulation marker was applied at about 5 mm from the lateral side of the outer margin of each lesion with an intervening distance of 5–6 mm by using a needle-knife. Marking was omitted if the outline of the lesion was clear after staining. The injection needle was extended by an endoscopic biopsy channel, and submucosal injection was employed at the sites indicated by the circumferential electrical coagulation marker until the lesion was lifted. The mucous membrane around the lesion was then cut with a needle-knife, and submucosal injection was performed while dissecting the lesion until the entire piece was removed. The wound surface was observed for errhysis, and small vessels exposed on the lesion site were clamped using electric coagulation forceps. The mucous membrane was occluded with a titanium clip around the wound surface if the wound was deep [Figure 1]. The specimens were then prepared through fixation with pins on a thin foam board and submersion in 10% formalin solution for pathological testing. Postoperative conventional fasting was performed for 1 day, and a fluid diet was arranged 3–5 days later. Hemostatics and antibiotics were applied to reduce the risk of complications.
|Figure 1: Endoscopic submucosal dissection. (a) Rectal carcinoid, (b) endoscopic ultrasonography, (c) lesion exposure, (d) clamping, (e) wound surface after removal, and (f) resection of tumor|
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Endoscopic mucosal resection marking
A mark was made with an electrical coagulation marker at about 0.5 cm from the margin of lesion. A multi-point injection with 1:100000 adrenaline saline was performed at the outer submucous membrane of the marked sites to induce swelling of the lesion and surrounding tissues (positive lifting sign). A transparent cap was then installed on the endoscopic head before placing the endoscope. The snare (Olympus SD-7P-1) was released and then tightened to resect the lesion (ERBE ICC 350, power 28 W). For wound treatment, hot biopsy forceps were used to clamp small vessels visible on the wound surface at the electrical coagulation site. Hemostatic and antimicrobial drugs were sprayed locally. A titanium clip was used to locally or completely close the wound surface if necessary.
Observation of indicators
Analysis and comparison were performed to determine differences in lesion size, operation time, histopathologically curative resection rate, complications, complete lesion resection rate, and postoperative recurrence rate among patients in both groups.
Follow-up duration was counted with respect to the day of surgery, and postoperative follow-up was conducted at the outpatient department or by phone interview. Enteroscopy was performed 1, 3, 6, and 12 months after the surgery, whereas biopsy was performed for suspected recurrent lesions. For the latter case, the time of tumor recurrence was recorded for the affected patients. The last follow-up was conducted in November 2015.
The measured data of all patients were reported as x¯ ± s, and t-test was used for comparison among groups. The relative number was used to represent enumeration data, and Chi-square test was used for comparison among groups. Median values were adopted to represent tumor recurrence in patients, and log-rank test in Kaplan–Meier survival curves was used for comparison among groups. Differences with P < 0.05 were considered statistically significant. SPSS 16.0 software (http://www-01.ibm.com/software/analytics/spss/) was used for all statistical analyses.
| > Results|| |
Comparison of surgical information
Operation time (25.2 ± 20.1 min) and wound surface diameter (36.2 ± 10.1 mm) were significantly higher in the ESD group than those in the EMR group (12.6 ± 8.4 min and 18.6 ± 5.9 mm, respectively) (P < 0.05). The differences in complete lesion and histopathologically curative resection rates between patients in both groups were not statistically significant (P > 0.05) [Table 2].
Comparison of complication
Suspicious hemorrhage occurred postoperatively in two patients in the EMR group, whereas hemorrhage did not recur after electric coagulation under endoscopy when the procedure was repeated in one patient. Suspicious delayed hemorrhage was detected in three patients in the ESD group; after electric coagulation under endoscopy was performed, hemorrhage did not recur in two patients. No perforation was noted in patients in both groups.
Results of follow-up
Postoperative follow-up was conducted 3–71 months, and the median follow-up time was 45 months. Recurrence was noted 32 months after surgery in one patient in the EMR group (4.5%), and no postoperative recurrence was noted in the ESD group.
| > Discussion|| |
Carcinoid tumor, also called argentaffine carcinoma, was first reported by Obendomr  in 1907. Modlin analyzed carcinoids in 13,715 patients and reported that digestive carcinoids accounted for 67.5% of all carcinoids. Other studies indicated that digestive carcinoids account for 60–90% of all carcinoids., In recent years, an increasing number of rectal carcinoids have been detected at early stages because of the constant development of endoscopic technology; however, the standard of endoscopic treatment for carcinoids has not been established. Traditional polypectomy is inapplicable for treatment of rectal carcinoid because it often presents with submucosal growth. Researchers reported that ESD and EMR achieved reliable clinical effects for treatment of rectal carcinoid., Gao et al. conducted preoperative diagnosis with ultrasonic endoscopy and ESD to treat eight patients with rectal carcinoid; the results revealed that ESD could effectively treat rectal carcinoid without invasion and metastasis to the intrinsic muscle layer. Yan  adopted EMR for treatment and follow-up of 11 patients with rectal carcinoid. This study revealed that EMR is a safe, minimally invasive, and effective treatment for rectal carcinoid with lesion diameters <1.0 cm and invasive depths not progressing further than the submucous membrane. These studies employed fewer cases (≤15 cases) than those in the present study, and the effectiveness and safety of ESD and EMR were not compared. Given these limitations, we performed a retrospective analysis on patients with rectal carcinoids who received ESD or EMR in our hospital in the last 6 years to determine the effectiveness and safety of both surgical treatments. We demonstrated that both ESD and EMR are effective and safe methods for treatment of rectal carcinoids. Moreover, ESD had less risk of recurrence, more complete resection rate which could provide more information for postoperative treatment. In these two surgical methods, each lesion is resected using a ligator and a transparent cap as well as suction; by contrast, suctioning is not adopted in the two latter methods. The results of further studies and extensive application of EMR indicate that entire lesions with <2 cm diameter can be removed, and lesions with concurrent scar fibrosis can also be ideally resected. Moreover, complete lesion resection rates and en bloc lesion resection rates are higher, whereas postoperative recurrence rates are low in EMR and ESD.
The effectiveness and safety of EMR and ESD for the treatment of rectal carcinoids were retrospectively compared in this study. Rectal carcinoids could be completely removed by both surgical methods. The primary postoperative complication was delayed hemorrhage, whereas nonsevere hemorrhage was noted in most cases in the study. The two surgical procedures present sufficient intraoperative electric coagulation and can be performed safely and smoothly.
Financial support and sponsorship
Project Sponsored by Xinxiang Municipal Science and Technology Foundation (No. ZGl3027).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]