Exploring the landscape of colorectal endoscopic submucosal dissection in Taiwan: In-depth investigation of complication risks

Colorectal endoscopic submucosal dissection (ESD) is a highly effective technique for resecting early colorectal neoplasms, and it has now gained recognition as the standard of care.^{1, 2} ESD has demonstrated remarkable success in achieving higher en bloc resection rates, with substantial evidence of its efficacy in Japan and Western countries.^{3, 4} Despite its proven effectiveness, concerns have arisen regarding the relatively higher incidence of perforation during colorectal ESD, particularly within the Taiwanese context. Conducting a comprehensive investigation into the specific risk factors for perforation during ESD procedures in Taiwan to better understand the challenges is crucial.

Yang et al. conducted this retrospective analysis of 161 cases, seeking to provide valuable insights into the management and prevention of ESD-associated perforation within the Taiwanese population.⁵ The study encompassed 161 patients who underwent colorectal ESD at a tertiary medical center in Taiwan between January 2014 and December 2019. Clinical risk factors for perforation during ESD were rigorously analyzed, including age, gender, tumor morphology, tumor size, tumor location, procedure duration, en bloc resection rate, histology, and the presence of submucosal fibrosis. Notably, the study revealed an impressive overall en bloc resection rate of 98.1%. Nevertheless, perforations were observed in 19.3% of the cases, affecting 31 out of the 161 patients. Importantly, it is worth highlighting that all perforations were effectively managed through endoscopic closure using hemoclips and nonsurgical approaches without the necessity for emergency surgery. Furthermore, multivariate analysis identified two independent risk factors for perforation during colorectal ESD. Severe submucosal fibrosis significantly increased the odds of perforation (odds ratio [OR] 3.06; 95% confidence interval [CI]: 1.23–7.59; P = .016), and the location of the lesion in the right colon demonstrated a higher risk of perforation (OR 4.54; 95% CI: 1.31–15.79; P = .017).⁵ In conclusion, this study provides important insights into the risk factors associated with perforation during colorectal ESD. Encouragingly, despite a relatively higher incidence of perforation, all patients in this study experienced favorable outcomes without the need for surgical intervention. The study demonstrates that colorectal ESD in Taiwan is an effective treatment with low rates of major complications.

In recent years, endoscopists in Taiwan have introduced several techniques to enhance colorectal ESD, a historically considered challenging, time-consuming, and high-risk procedure. These new techniques have brought renewed hope and improved outcomes to ESD procedures. First, Chang et al. have developed the Diving, Lifting, and Horizontal dissection technique with the loop–clip traction method, which streamlines mucosal trimming and facilitates the creation of mucosal flaps, ultimately increasing surgical efficiency.⁶ By employing this standardized approach, dissection speed can be enhanced, potentially reducing the likelihood of complications, particularly in cases associated with submucosal fibrosis resulting from prior biopsies.⁶ With conventional traction methods sometimes falling short, Chou et al. introduced a novel double endoscopy ESD with snare traction.⁷ The retrospective study showed a median procedure time of 32.45 min for double-scope ESD, significantly shorter than the 54.61 min for matched conventional ESD. All lesions were completely resected without major complications.⁷ Double endoscopy ESD can be used effectively to remove lesions in difficult anatomical areas.⁸ Wu et al. also proposed that the snare tip is a viable alternative tool for colorectal ESD in a specific population, particularly when specialized ESD knives are unavailable.⁹ While it may result in a slower dissection pace, it remains a recommended technique, especially for patients in developing countries or those with limited financial resources.⁹

In recent years, physicians in Taiwan have contributed to the application, development, and advancement of ESD and its related techniques. Their dedication to research and innovation has played a pivotal role in pushing the boundaries of medical practice and improving patient care in this field. In a study conducted by Chou et al., the feasibility of utilizing ESD for treating superficial pharyngeal squamous cell carcinoma was demonstrated in 10 patients with 11 lesions.¹⁰ The results revealed an impressive en bloc resection rate of 91% (10/11) and a complete resection rate of 36% (4/11). This study establishes that ESD for superficial pharyngeal cancer is a secure and viable treatment option, offering favorable and promising results in Taiwan. Endoscopic management for subepithelial gastrointestinal lesions has demonstrated highly favorable outcomes in Taiwan.¹⁰ The introduction of endoscopic suturing systems has empowered Taiwanese endoscopists to manage large gastric and duodenal gastrointestinal stromal tumors effectively, marking the first case reports of such procedures in Asia.^{11, 12} Peroral endoscopic myotomy for achalasia, antireflux mucosal intervention for gastroesophageal reflux, and gastric peroral endoscopic myotomy for gastroparesis in Taiwan have yielded exceptionally positive clinical outcomes.^13-15

The acceptance of ESD and its related procedures in Taiwan is gradually increasing. Gaining a deeper understanding of colorectal ESD provides valuable insights and helps mitigate the risk of complications. According to this study, severe submucosal fibrosis and tumor location in the right colon have been identified as independent risk factors for perforation during ESD. The perforation rate reached 19.3%, but fortunately, all cases were successfully managed through endoscopic closure without requiring surgical rescue. As a result, it is imperative to emphasize more cautious and proactive management for colorectal ESD in patients at a high risk of perforation.

The authors declare no conflicts of interest.