Difficult Manipulation is One of the Risk Factors for Incomplete Resection in Colorectal Endoscopic Submucosal Dissection

Naohisa Yoshida, Nilesh Fernandopulle, Takaaki Murakami, Ryohei Hirose, Kiyoshi Ogiso, Yutaka Inada, Osamu Dohi, Tetsuya Okayama, Kazuhiro Kamada, Kazuhiko Uchiyama, Takeshi Ishikawa, Osamu Handa, Hideyuki Konishi, Yuji Naito, Akio Yanagisawa, Yoshito Itoh


AIM: Colorectal endoscopic submucosal dissection (ESD) remains a difficult procedure, even for experts. Difficult manipulation during procedure is one of the most important problems in colorectal ESD. In this study, we analyzed the risk factors for incomplete resection in colorectal ESD, focusing on difficult manipulation.

MATERIALS AND METHODS: We retrospectively analyzed 405 consecutive tumors for which ESD was performed at the Kyoto Prefectural University of Medicine from 2010 to 2013 by a single expert endoscopist with extensive ESD experiences. The relationship between incomplete resection and clinicopathological factors were examined. Additionally, multivariate analysis was performed to examine risk factors of difficult manipulation.

RESULTS: The rate of incomplete resection was 3.2%. The rates of severe fibrosis, difficult manipulation, and perforation were 10.8%, 23.5%, and 2.7%, respectively. Multivariate analyses showed that severe fibrosis (OR: 26.395, 95% CI: 6.587-105.764, p < 0.001), difficult manipulation (OR: 4.575, 95% CI: 1.200-17.436, p = 0.026), and tumor size ≥ 50 mm (OR: 4.452, 95% CI: 1.061-18.688), were significantly related with incomplete en bloc resection. Multivariate analyses showed that right-sided colon (OR: 9.762, 95% CI: 2.119-44.972, p = 0.003), left-sided colon (OR: 8.834, 95% CI: 1.788-43.643, p = 0.008), severe breathing movement (OR: 2.648, 95% CI: 1.371-5.116, p = 0.004), insertion time (per 1min) (OR: 1.094, 95% CI: 1.016-1.179, p = 0.018), and procedure time (OR: 0.004, 95% CI: 0.000-0.437, p = 0.022) were significantly related with difficult manipulation.

CONCLUSION: Severe fibrosis, difficult manipulation, and tumor size ≥ 50 mm were related with incomplete resection for colorectal ESD even in expert hands.


Difficult manipulation; ESD; Colorectal polyp

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