SA104 - Use of Snare Tip Endoscopic Submucosal Dissection in the Management of Complex Endoluminal Colon Lesions

Purpose/Background: Endoscopic submucosal dissection (ESD) is a potential organ sparing procedure that can be used to resect complex colon lesions that would traditionally be treated with colectomy. Following submucosal injection with a lifting agent, the lesion is then dissected free from the underlying tissue with the aid of a specialized electrocautery device. These proprietary devices can range from hundreds to thousands of dollars, which may prohibit ESD from being performed at some institutions. Previous studies have shown that it is feasible to use the tip of a traditional polypectomy snare to perform colonic ESD (SNT ESD). In this study, we aimed to evaluate the safety and clinical outcomes of patients who underwent SNT ESD for complex colon lesions at our institution.

Methods/Interventions: Patients who underwent SNT ESD were identified from a prospectively maintained database of patients undergoing ESD at our center from 2014 to 2023. Demographic and clinical data were collected for all patients. SNT ESD was conducted by two colorectal surgeons using standardized ESD technique. SNT ESD was used preferentially in lesions that lifted well after submucosal injection as there is a slightly larger thermal spread than traditional ESD knives. Patients where a hybrid technique that included endoscopic mucosal resection (EMR) were excluded. Procedural complications, en bloc resection rates, pathologic results, and recurrence rates on follow up colonoscopies were noted.

Results/Outcomes: A total of 121 patients who underwent SNT ESD were identified via EMR registry inquiry. The average patient age at SNT ESD was 64.9+/-10.2 years. Ninety-nine of the procedures (81.8%) were conducted in the endoscopy suite and 22 (18.2%) were conducted in the OR. The average size of the lesions was 28.8+/-9.84 mm. The lesions were in the cecum (45), ascending colon (28), transverse colon (8), descending colon (7), sigmoid colon (7), and rectum (5). The average SNT ESD procedure duration was 37.1+/- 29.8 min. Ninety-nine (81.8%) specimens were excised en bloc and 22 (18.2%) were excised in a piecemeal fashion, based on pathology specimen. One hundred and fourteen (94.2%) of the lesions were benign and 7 (5.78%) had invasive adenocarcinoma. Four of these patients underwent colectomy for positive margins or depth of invasion >1000µm. There were 2 intraprocedural perforations during SNT ESD. One perforation was closed with laparoscopic suturing and the second was repaired with endoscopic clipping, admission, and IV antibiotics. Both patients recovered and were discharged within 3 days. Seven (5.79%) patients were readmitted within 30 days with hematochezia, all of whom were managed by observation alone. Of the 76 patients who had a follow-up colonoscopy within our system after SNT ESD, 6 (7.89%) had a recurrent polyp at the site of ESD. All recurrent polyps were able to be resected with simple snare polypectomy.

Conclusion/Discussion: SNT ESD is a feasible technique for the endoscopic management of complex endoluminal colon lesions, with a comparable safety profile to traditional ESD. This approach is attractive because it utilizes an easily accessible and cost-effective polypectomy snare, potentially increasing the accessibility of ESD for endoscopists.