ORIGINAL ARTICLE

The Effectiveness of Endoscopic Submucosal Resection With a Ligation Device for Small Rectal Carcinoid Tumors: Focused on Previously Biopsied Tumors Yeong-Cheol Im, MD,* Seok Won Jung, MD, PhD,w Hee Jeong Cha, MD, PhD,z Song-Soo Yang, MD,* Gyu Yeol Kim, MD, PhD,* Young Arm Yi, MD,w Jae Ho Park, MD,w Byung Gyu Kim, MD, PhD,w and In Du Jeong, MD, PhDw

Purpose: To evaluate the effectiveness of endoscopic submucosal resection with a ligation device (ESMR-L) on histologic complete resection for the treatment of small rectal carcinoid tumors in comparison with the treatment with endoscopic mucosal resection (EMR) alone. Methods: Thirty-five patients with small rectal carcinoid tumors were enrolled prospectively for ESMR-L, and we retrospectively reviewed 74 carcinoid tumor patients who underwent EMR. The comparison between ESMR-L and EMR groups was analyzed including endoscopic and histologic complete resection and complications after resection. We also evaluated the associations of histologic complete resection with clinical and procedure-related factors. Results: The histologic complete resection rate was significantly higher in ESMR-L than in EMR (94.3% vs. 75.7%, P = 0.019). In addition, the resection time was significantly shorter in ESMR-L than in EMR (4.16 ± 1.48 min vs. 5.11 ± 2.47 min, respectively, P = 0.014). Moreover, previously biopsied rectal carcinoid tumors were significantly associated with histologic incomplete resection, especially in patients who underwent EMR (odds ratio, 6.28; 95% confidence interval, 1.92-20.58; P = 0.002). Conclusions: Compared with EMR, ESMR-L is a safe and effective method for histologic complete resection of small rectal carcinoid tumors, especially in patients with previously biopsied carcinoid tumors. Key Words: carcinoid, rectum, endoscopy, resection, ligation

(Surg Laparosc Endosc Percutan Tech 2014;24:264–269)

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ectal carcinoid tumors represent 1.1% to 1.3% of all rectal tumors and comprise 12.6% of all carcinoid tumors.1,2 A recent study reported that the incidence of rectal carcinoid tumors has increased markedly, the rectum being the most common site of occurrence in the gastrointestinal tract.3 These tumors can show a broad range of clinical behavior, from benign to disseminated and metastatic. Their clinical behavior is influenced by the tumor size, which is generally proportional to the metastatic Received for publication August 21, 2012; accepted October 16, 2012. From the Departments of *General Surgery; wInternal Medicine; and zPathology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea. The authors declare no conflict of interest. Reprints: Seok Won Jung MD, PhD, Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 290-3 Jeonha-dong, Dong-gu, Ulsan 682-714, Republic of Korea (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins

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potential.4–6 Rectal carcinoid tumors smaller than 10 mm in diameter rarely metastasize, and thus are usually managed with local excision such as endoscopic resection.7,8 Conventional endoscopic mucosal resection (EMR) has been the treatment of choice for small rectal carcinoid tumors. However, histologic complete resection is often difficult to achieve using EMR because most rectal carcinoid tumors are usually located in the submucosa rather than confined to the mucosa, resulting in the failure of histologic complete resection.3 Moreover, diagnostic biopsies at the time of tumor detection may lead to scar formation, which may cause unpredicted difficulty in the endoscopic resection.9 Previous studies reported that tumor involvement of the resection margin was found in 14% to 62% cases of EMR procedures.10,11 A few studies have reported the effectiveness of the endoscopic submucosal resection technique with a ligation device (ESMR-L) for complete resection of carcinoid tumors. Their results suggested that ESMR-L showed a higher rate of histologic complete resection without significant complications compared with conventional EMR.12–14 However, previous studies did not describe the association of histologic complete resection of carcinoid tumors with clinical and procedure-related factors, especially previous history of diagnostic biopsies. Thus, in the present study, we conducted a prospective study comparing ESMR-L with conventional EMR for the treatment of small rectal carcinoid tumors. In addition, we investigated the associations of histologic complete resection with clinical and procedure-related factors including previously performed biopsies in patients with small rectal carcinoid tumors.

PATIENTS AND METHODS Patients We prospectively performed ESMR-L in 35 consecutive patients with rectal carcinoid tumors during the period from January 2008 to December 2010 at the Ulsan University Hospital, Ulsan, Korea. For a comparison, we retrospectively recruited 74 control patients with rectal carcinoid tumors who underwent conventional EMR between January 2002 and December 2007. The indication for endoscopic treatment was decided on the basis of the recommendations of previous reports.15,16 Although there is no consensus on the appropriate treatment for a rectal carcinoid tumor size of 10 to 19 mm,15 the Japanese multicenter survey recommends initial endoscopic resection for tumor sizes in the range from 11 to 15 mm confined to the

Surg Laparosc Endosc Percutan Tech



Volume 24, Number 3, June 2014

Surg Laparosc Endosc Percutan Tech



Volume 24, Number 3, June 2014

submucosal layer.16 Thus, we selected patients with rectal carcinoid tumors

The effectiveness of endoscopic submucosal resection with a ligation device for small rectal carcinoid tumors: focused on previously biopsied tumors.

To evaluate the effectiveness of endoscopic submucosal resection with a ligation device (ESMR-L) on histologic complete resection for the treatment of...
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