Curative endoscopic submucosal dissection of large nonpolypoid superficial neoplasms in ulcerative colitis (with videos)

Background: Endoscopic resection of superficial neoplasms in inflammatory bowel disease (IBD) is appropriate if a complete resection can be achieved. However, EMR is ineffective for large, nonpolypoid neoplasms in IBD due to submucosal fibrosis, and no data are available on the efficacy of endoscopic submucosal dissection (ESD). Objective: To assess ESD feasibility and efficacy for large, nonpolypoid neoplasms in patients with IBD. Design: Prospective case series. Setting: Multicenter: Italian and Japanese centers. Patients: Consecutive patients with long-standing ulcerative colitis and a superficial nonpolypoid neoplasm, >20 mm within the colitic mucosa. Intervention: Neoplasm characterization and delineation by chromoscopy and narrow-band imaging. ESD performed according to the standard technique. Main Outcome Measurements: Feasibility, safety, curative resection rates. Results: Nine patients with 10 neoplasms were included (7 and 3 in the Italian and Japanese centers, respectively). Neoplasms were laterally spreading tumors-non-granular in 5 cases, in the left side of the colon in 7, had median size of 33 mm, and were associated with scar in 5 cases. Margin delineation was difficult in 5 cases. Submucosal fibrosis was present in 9 cases. ESD was en bloc with negative margins (R0) in 8 cases, and curative in 7. No endoscopic invisible dysplasia or cancer was found during the follow-up (median 24 months, range 6-72 months) at the resection site and elsewhere within the colitic mucosa. Limitations: Small series. Conclusion: ESD achieves curative resections in patients with IBD, but the procedure is difficult because of the high prevalence of submucosal fibrosis. Patients need to be accurately evaluated before resection and adhere to strict long-term follow-ups.