Clin Endosc.  2019 Mar;52(2):120-128. 10.5946/ce.2019.047.

Endoscopic Submucosal Dissection for Colitis-Associated Dysplasia

• Yang DH
• Rey I

• KMID: 2447668
• DOI: http://doi.org/10.5946/ce.2019.047

Abstract

Dysplasia is a precancerous lesion of colorectal cancer in patients with long-standing inflammatory bowel diseases (IBDs), such as ulcerative colitis and Crohn's disease. Recent guidelines suggest endoscopic resection as a key modality for the treatment of endoscopically resectable dysplasia in patients with colitis. Endoscopic submucosal dissection (ESD) has been suggested as one of the therapeutic options for dysplasia that is potentially resectable but not suitable for the conventional endoscopic mucosal resection technique. Several recent studies supported the feasibility of ESD for the treatment of colitis-associated dysplasia in terms of the en bloc and complete resection rates and the risk of procedure-related complications. However, these studies were performed exclusively in expert centers. Moreover, the local and metachronous recurrence rates were relatively high, and long-term outcome data are still lacking. Endoscopists should be highly skilled in colorectal ESD and have an intensive understanding of not only the lesions but also the conditions of patients with IBDs. Therefore, the decision to perform ESD for colitis-associated dysplasia should be made scrupulously after careful discussion with patients, in collaboration with a multidisciplinary IBD team including physicians, surgeons, and pathologists specialized in IBDs.

Keyword

Inflammatory bowel disease; Ulcerative colitis; Dysplasia; Endoscopic submucosal dissection

MeSH Terms

Colitis
Colitis, Ulcerative
Colorectal Neoplasms
Cooperative Behavior
Crohn Disease
Humans
Inflammatory Bowel Diseases
Recurrence
Surgeons

Figure

• 

  Fig. 1. (A, B) A classic non-lifting sign was observed in sporadic deep submucosal invasive cancer. The lesion was not lifted; however, the surrounding mucosa was elevated after submucosal injection. The final histology of this lesion was SM3 adenocarcinoma. (C, D) A classic non-lifting sign was observed in colitis-associated dysplasia. The dysplasia itself was not lifted; however, the surrounding mucosa was lifted after submucosal injection. Its colectomy specimen revealed an adenocarcinoma invading the proper muscle (T2 stage). (E, F) A diffuse non-lifting sign was observed in colitis-associated dysplasia located on the extensive scar changes. Neither the dysplasia nor the surrounding mucosa was lifted after submucosal injection. The final histology of this lesion was lowgrade dysplasia.

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  Fig. 2. Representative example of endoscopic submucosal dissection for colitis-associated dysplasia. (A) Large, non-ulcerated Paris type O-IIa dysplasia with a distinct border in the rectum. (B) Mucosal incision was performed after submucosal injection. (C) Mild but diffuse submucosal fibrosis and submucosal fat deposition. (D-F) The colonoscope was changed into a gastroscope to expose the submucosal layer more effectively, and en bloc resection was achieved. The final histology revealed low-grade dysplasia (42×40 mm in size, with clear lateral and vertical margins).

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  Fig. 3. (A, B) Diathermic marks were made; the border of the dysplasia was clearly distinguishable under dye chromoendoscopy. (C, D) After submucosal injection, the border of the lesion became less distinguishable. (E, F) Endoscopic submucosal dissection was performed along the diathermic marks, and en bloc complete resection was possible. The final histology was low-grade dysplasia (15×10 mm in size, with clear lateral and vertical margins).

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