institute for decision making for therapeutic endoscopy ...€¦ · mr amyn haji ma md msc frcs...
TRANSCRIPT
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Decision making for
treatment of rectal
lesions
Mr Amyn Haji MA MD MSc FRCS
Consultant Colorectal &
Laparoscopic Surgeon
Director of Endoscopy & Colorectal
Surgery
King’s College Hospital, London
Institute for
Therapeutic
Endoscopy
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Endoscopic mucosal resection
Endoscopic submucosal dissection
Transanal endoscopic microsurgery / Laparoscopic surgery
Decisions often made on local expertise rather than diagnosis
Options for resection Page 1
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Discussion regarding risk of lymph node metastases
Technically resectable by ESD for early submucosal invasion
More important to resect high risk benign lesions
Early rectal cancer Page 2
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© UEG. 2014
Aim for quality specimen
When submucosal invasion is suspected, we should provide the
pathologist with a single fragment which includes the submucosa
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Accurate diagnosis
King’s approach Page 4
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Morphology of colorectal polyps
Assessment
Magnification colonoscopy
Pit pattern classification
Spectral imaging
High frequency colonoscopic ultrasound
Endoscopic resection – EMR/ESD
Lesion assessment Page 5
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Pit pattern classification
I II
IIILIIIS IV
VI VN
From Showa Univ. Japan
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Vascular pattern classification
From Showa Univ. Japan
faintnormal
network dense
irregular sparse
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High frequency mini-probes
7.5 – 30 MHz
Introduced through instrument
channel
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20 MHz ultrasound
9
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20 MHz ultrasound
96% accuracy in differentiation between mucosal and submucosal lesions
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Benign colorectal polyps
LST granular
homogenous – benign pit pattern
Comorbidity
Selection for Endoscopic Mucosal Resection
(EMR)
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Homogeneous
(H)
Nodular mixed
(M)
Pseudo depressed
(PD)
Submucosal invasive rates of LSTs
Flat elevated
(F)
90/218**41.3%
4/514*0.8%
72/37919.0%
83/8519.8%
Granular type(LST-G)
Non granular type(LST-NG)
0/2030%
size (mm)
10-19 20-29 30-39
1/1420.7%
1/741.4%
16/10315.5%
18/8321.7%
28/9629.2%
40/8845.5%
18/2766.7%
26/4995.2%
30/23312.9%
12/7316.4%
total
5/4610.9%
40-
2/952.1%
33/14722.4%
15/4632.6%
4/757.1%
**Submucosal invasive rate is very high in PD
*Submucosal invasive rate is very low in H
Apr. 2001~Dec.2012
249/196212.7%
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Benign pit – EMR or ESD
Decision making for large LST mixed nodular type Page 16
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© UEG. 2014
Matsuda et al. Am J Gastroenterol 2008; 103: 2700
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Benign pit pattern
High frequency ultrasound – mm maintained – EMR
Early submucosal invasion - ESD
Decision making for large LST mixed nodular type Page 19
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granular type
non-granular type
Laterally spreading tumor (LST)
homogeneous type (Homo) nodular mixed type (Mix)
flat-elevated type (F) pseudo-depressed type (PD)
Kudo S:Early Colorectal Cancer, IGAKU-SHOIN, 150-154, 1996
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Homogeneous
(H)
Nodular mixed
(M)
Pseudo depressed
(PD)
Submucosal invasive rates of LSTs
Flat elevated
(F)
90/218**41.3%
4/514*0.8%
72/37919.0%
83/8519.8%
Granular type(LST-G)
Non granular type(LST-NG)
0/2030%
size (mm)
10-19 20-29 30-39
1/1420.7%
1/741.4%
16/10315.5%
18/8321.7%
28/9629.2%
40/8845.5%
18/2766.7%
26/4995.2%
30/23312.9%
12/7316.4%
total
5/4610.9%
40-
2/952.1%
33/14722.4%
15/4632.6%
4/757.1%
**Submucosal invasive rate is very high in PD
*Submucosal invasive rate is very low in H
Apr. 2001~Dec.2012
249/196212.7%
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LST – non granular type
Vi pit pattern
?Fibrosis
Up to 30% of endoscopic Vi pit pattern histologically Vn
Not good at differentiating Vi low grade vs high grade
Selection for Endoscopic Submucosal Dissection
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20 MHz ultrasound
96% accuracy in differentiation between mucosal and submucosal lesions
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ESD
Vn
Rectum
Colon
Pit Vi
Treatment of suspected cancer
Laparoscopic surgery
TEMS
Laparoscopic surgery
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Patients often have previous attempted resection
Fibrosis
Large lesions
Problems in our tertiary referral practice Page 25
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King’s data - challenges
485 cases endoscopic resection with 12 month follow up
124 ESD cases
Mean Age 71.8 (SD=11)
Mean size of polyp = 55.2 +/-30.1mm (range 20mm – 160mm)
91 lesions > 8 cm (21%)
30% previous failed EMR ; 60% - previous snare attempt or > 6 biopsies
Follow up endoscopy at 3, 12 months
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Fibrosis Page 27
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Endoscopic submucosal dissection (ESD) Page 28
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LST-G nodular mixed
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LST granular homogenous type – EMR
LST granular mixed nodular type – ESD / (en bloc of nodule)
LST NG – ESD
Rational approach for endoscopic treatment of
colorectal lesions Page 34
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ESD increasing its presence in tertiary referral centres
Education regarding biopsy and attempted resection
Endoscopic diagnosis is the key for appropriate decision making
regarding EMR or ESD
Summary Page 35
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