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16.4months for patients who underwent chemotherapy alone (hazard ratio, 1.60;
95% condence interval, 1.43–1.78) [21]. The authors acknowledged the potential
for bias, since the reasons for resection and nonresection were not available.
Moreover, data from patients who did not meet the inclusion criteria for the trials,
such as morbidity or mortality after primary tumor resection, were not available.
P. Goredo and M. R. Weiser
Morbidity andMortality
Resection of the primary tumor is associated with high morbidity. In the iPACS
trial, grade≥2 complications occurred in 38% of the patients and grade≥3 complications occurred in 21% [14]. The rates of anastomotic leak and 30-day mortality
were 4%. Additionally, both grade ≥ 2 and grade≥ 3 nonhematological adverse
events were more frequent than after chemotherapy alone (87% vs. 77% and 48%
vs. 34%, respectively). Similarly, the PTR trial found higher morbidity in patients
who underwent resection, with postoperative complications in 19% of the patients,
including 1 death, and a 30-day readmission rate of 12% [13]. There were no cases
of anastomotic leakage. The rate of chemotherapy-related toxicities was approximately 27% in both groups. The CAIRO4 trial reported comparable rates of
grade≥3 toxicity in the two groups (23% for resection vs. 30% for chemotherapy
alone, P=0.25) [15]. However, within 60days from randomization, mortality was
11% in the resection group vs. 3% in the chemotherapy group (P=0.03).
Postoperative recovery and morbidity can signicantly delay or sometimes prevent initiation of chemotherapy. This has frequently been considered a drawback to
resection of the primary tumor in patients with metastasis. In the iPACS trial, the
median time to initiation of systemic chemotherapy after surgery was 34days, compared with 9days after enrollment for patients who did not undergo resection [14].
In the PTR trial, the median interval from surgery to initiation of systemic chemotherapy was 25days [13]. In the CAIRO4 trial, the median interval from randomization to initiation of systemic chemotherapy was 7days for patients who did not
undergo resection and 46days for patients who did [15].
Conversion toResectability
The guidelines of the American Society of Colon and Rectal Surgeons advise
against primary tumor resection in patients with asymptomatic unresectable stage
IV disease and strongly recommend neoadjuvant chemotherapy as a means of facilitating conversion to resectability [22]. This recommendation is based in part on a
2020 systematic review of 20 trials, which found that neoadjuvant treatment with
oxaliplatin- or irinotecan-based chemotherapy plus bevacizumab or cetuximab produced a response in 55–85% of patients and conversion to resectability in 10–61%
of patients, with R0 resection rates as high as 54% [23]. The PTR and iPACS trials
reported conversion to resectability in 18 and 6% of patients randomized to chemotherapy alone, respectively [13, 14].
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175
Natural History ofNonresected Primary Disease
One argument for resecting the primary tumor electively is potential prevention of
obstruction, perforation, severe bleeding, or another cancer-related complication.
However, these events are relatively rare. In the multicenter prospective phase II
trial NSABP C-10, in which patients with an asymptomatic primary tumor and
unresectable metastases received oxaliplatin-based chemotherapy and bevacizumab, with median follow-up of 21months, 14% of the patients had major morbidity related to the primary tumor and 12% required an operation, mostly for
obstruction [12]. A 2019 population-based SEER study of 4692 patients with stage
IV colorectal cancer (74% of the patients had colon cancer and 26% had rectal cancer) obtained similar results, with unplanned operations required in only 12% of the
patients [24]. In the PTR trial, 4 (18%) of the 22 patients assigned to chemotherapy
alone underwent surgery during chemotherapy and 5 (23%) of the 22 patients
required interventional therapy (colonic stent placement or salvage radiotherapy)
[13]. The rate of palliative surgery in patients assigned to chemotherapy alone was
13% in the iPACS trial and 6% in the CAIRO4 trial [14, 15]. These data indicate that
if upfront resection was performed routinely in order to prevent possible acute surgery during chemotherapy, approximately 5 to 10 patients would undergo an unnecessary intervention in order to prevent an emergency intervention in 1 patient.
Resection of an asymptomatic primary tumor, therefore, does not provide a signicant prophylactic benet for most patients.
It is important to note that complications associated with an untreated primary
tumor may be more common for rectal cancer than for colon cancer. In a recent
single-institution series from Memorial Sloan Kettering Cancer Center, of 190
patients who did not undergo an upfront or elective intervention for the primary
tumor, 68 (36%) experienced complications; 42 (62%) of the 68 patients ended up
with a diverting ostomy [25]. These data suggest that closer follow-up may be
needed for metastatic rectal cancer than for metastatic colon cancer.
Recommendations Based ontheData
Asymptomatic patients with unresectable metastatic colorectal cancer should proceed with systemic therapy and not undergo resection of the primary tumor (evidence quality high; strong recommendation).
Personal View oftheData
Until recently, the value of resecting an asymptomatic primary tumor in patients
with incurable metastatic colon cancer was debatable, based on biased retrospective
series. We now have data from randomized controlled trials demonstrating the futility of resection for most patients. Immediate surgery is associated with morbidity
and is not associated with longer survival, and it can delay initiation of systemic
chemotherapy. Timely intervention can rescue patients who develop complications
related to the primary lesion.
Clinical judgment should guide the decision-making process, with the goal of
optimizing survival and balancing the quality of life. Our current practice is to
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P. Goredo and M. R. Weiser
administer chemotherapy rst, based on the fact that in a subset of patients, current
multimodal therapies substantially prolong life and facilitate the possibility of a
curative resection.
When developing a treatment plan, patients’ symptoms, colonoscopy reports,
and cross-sectional images should be carefully reviewed. In patients who present
with anemia, the symptoms can be managed medically, with improvement within
two to four cycles of chemotherapy. Similarly, upfront chemotherapy with close
observation may be safely employed in patients with mild obstructive symptoms,
which generally improve with systemic treatment. However, when patients present
with signicant symptoms or evidence of proximal dilation on CT, surgical intervention in the form of a diverting ostomy or tumor resection should be considered,
keeping in mind the signicant risk of complications and potential delay in
chemotherapy.
Future investigations may identify clinicopathologic or molecular factors that
can be used to predict which patients may indeed benet form upfront surgery.
Currently, based on the evidence, the standard of care should be upfront chemotherapy, evaluation of response, estimation of prognosis, and further discussion in a
multidisciplinary setting.
References
1. U.S.Cancer Statistics Working Group. U.S.Cancer Statistics Data Visualizations Tool, based
on 2020 submission data (1999–2018) www.cdc.gov/cancer/dataviz: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention and National Cancer
Institute; 2021.
2. Corsini EM, Mitchell KG, Correa A, Morris VK, Antonoff MB.Effect of primary colorectal
cancer tumor location on survival after pulmonary metastasectomy. J Thorac Cardiovasc Surg.
2021;162(1):296–305.
3. Tomlinson JS, Jarnagin WR, DeMatteo RP, Fong Y, Kornprat P, Gonen M, et al. Actual
10-year survival after resection of colorectal liver metastases denes cure. J Clin Oncol.
2007;25(29):4575–80.
4. Engstrand J, Nilsson H, Strömberg C, Jonas E, Freedman J.Colorectal cancer liver metastases – a population-based study on incidence, management and survival. BMC Cancer.
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5. National Comprehensive Cancer Network. NCCN clinical practical guidelines in oncology:
colon cancer: NCCN; (updated Version 1.2019 – March 15, 20192019). Available from:
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6. Weiser MR.Primum non nocere: a word of caution regarding prophylactic colectomy in the
setting of incurable metastatic disease. Ann Surg Oncol. 2011;18(12):3229–31.
7. Yamada Y, Takahari D, Matsumoto H, Baba H, Nakamura M, Yoshida K, etal. Leucovorin,
uorouracil, and oxaliplatin plus bevacizumab versus S-1 and oxaliplatin plus bevacizumab in
patients with metastatic colorectal cancer (SOFT): an open-label, non-inferiority, randomised
phase 3 trial. Lancet Oncol. 2013;14(13):1278–86.
8. Yamazaki K, Nagase M, Tamagawa H, Ueda S, Tamura T, Murata K, etal. Randomized
phase III study of bevacizumab plus FOLFIRI and bevacizumab plus mFOLFOX6 as rstline treatment for patients with metastatic colorectal cancer (WJOG4407G). Ann Oncol.
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9. Ahmed S, Leis A, Fields A, Chandra-Kanthan S, Haider K, Alvi R, etal. Survival impact of
surgical resection of primary tumor in patients with stage IV colorectal cancer: results from a
large population-based cohort study. Cancer. 2014;120(5):683–91.
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10. Ishihara S, Hayama T, Yamada H, Nozawa K, Matsuda K, Miyata H, etal. Prognostic impact
of primary tumor resection and lymph node dissection in stage IV colorectal cancer with unresectable metastasis: a propensity score analysis in a multicenter retrospective study. Ann Surg
Oncol. 2014;21(9):2949–55.
11. Poultsides GA, Servais EL, Saltz LB, Patil S, Kemeny NE, Guillem JG, etal. Outcome of
primary tumor in patients with synchronous stage IV colorectal cancer receiving combination
chemotherapy without surgery as initial treatment. J Clin Oncol. 2009;27(20):3379–84.
12. McCahill LE, Yothers G, Sharif S, Petrelli NJ, Lai LL, Bechar N, etal. Primary mFOLFOX6
plus bevacizumab without resection of the primary tumor for patients presenting with surgically unresectable metastatic colon cancer and an intact asymptomatic colon cancer: denitive
analysis of NSABP trial C-10. J Clin Oncol. 2012;30(26):3223–8.
13. Park EJ, Baek JH, Choi GS, Park WC, Yu CS, Kang SB, et al. The role of primary tumor resection in colorectal cancer patients with asymptomatic, synchronous, unresectable metastasis: a
multicenter randomized controlled trial. Cancers (Basel). 2020;12(8):2306.
14. Kanemitsu Y, Shitara K, Mizusawa J, Hamaguchi T, Shida D, Komori K, et al. Primary tumor
resection plus chemotherapy versus chemotherapy alone for colorectal cancer patients with
asymptomatic, synchronous unresectable metastases (JCOG1007; iPACS): a randomized clinical trial. J Clin Oncol. 2021;39(10):1098–107.
15. van der Kruijssen DEW, Elias SG, Vink GR, van Rooijen KL, t Lam-Boer J, Mol L, etal.
Sixty-day mortality of patients with metastatic colorectal cancer randomized to systemic treatment vs primary tumor resection followed by systemic treatment: the CAIRO4 phase 3 randomized clinical trial. JAMA Surg. 2021;156(12):1093–101.
16. Moritani K, Kanemitsu Y, Shida D, Shitara K, Mizusawa J, Katayama H, etal. A randomized
controlled trial comparing primary tumour resection plus chemotherapy with chemotherapy
alone in incurable stage IV colorectal cancer: JCOG1007 (iPACS study). Jpn J Clin Oncol.
2020;50(1):89–93.
17. Alawadi Z, Phatak UR, Hu CY, Bailey CE, You YN, Kao LS, etal. Comparative effectiveness of
primary tumor resection in patients with stage IV colon cancer. Cancer. 2017;123(7):1124–33.
18. Ahmed S, Fields A, Pahwa P, Chandra-Kanthan S, Zaidi A, Le D, et al. Surgical resection of
primary tumor in asymptomatic or minimally symptomatic patients with stage IV colorectal
cancer: a Canadian province experience. Clin Colorectal Cancer. 2015;14(4):e41–7.
19. Shida D, Hamaguchi T, Ochiai H, Tsukamoto S, Takashima A, Boku N, et al. Prognostic
impact of palliative primary tumor resection for unresectable stage 4 colorectal cancer: using
a propensity score analysis. Ann Surg Oncol. 2016;23(11):3602–8.
20. Tarantino I, Warschkow R, Worni M, Cerny T, Ulrich A, Schmied BM, et al. Prognostic relevance of palliative primary tumor removal in 37,793 metastatic colorectal cancer patients: a
population-based, propensity score-adjusted trend analysis. Ann Surg. 2015;262(1):112–20.
21. van Rooijen KL, Shi Q, Goey KKH, Meyers J, Heinemann V, Diaz-Rubio E, etal. Prognostic
value of primary tumour resection in synchronous metastatic colorectal cancer: individual
patient data analysis of rst-line randomised trials from the ARCAD database. Eur J Cancer.
2018;91:99–106.
22. Vogel JD, Felder SI, Bhama AR, Hawkins AT, Langenfeld SJ, Shaffer VO, etal. The American
Society of Colon and Rectal Surgeons clinical practice guidelines for the Management of
Colon Cancer. Dis Colon Rectum. 2022;65(2):148–77.
23. Bolhuis K, Kos M, van Oijen MGH, Swijnenburg RJ, Punt CJA.Conversion strategies with
chemotherapy plus targeted agents for colorectal cancer liver-only metastases: a systematic
review. Eur J Cancer. 2020;141:225–38.
24. Lorimer PD, Motz BM, Kirks RC, Han Y, Symanowski JT, Hwang JJ, etal. Frequency of
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25. Tan WJ, Patil S, Guillem JG, Paty PB, Weiser MR, Nash GM, etal. Primary tumor-related
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primary tumor. Dis Colon Rectum. 2021;64(1):45–52.
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ofLarge Colonic Polyps?
15
SumeyyeYilmaz andEmreGorgun
Introduction
Colorectal cancer is the third most commonly diagnosed cancer and second leading
cause of cancer-related mortality globally [1, 2]. Based on adenoma-carcinoma
sequence theory, early detection and removal of colorectal neoplasms is essential
for improving cancer incidence and mortality [3]. Ideally, a neoplastic lesion should
be resected in one-piece (en-bloc) with histologically negative margins (R0).
Fortunately, 80–90% of polyps are ≤1cm and can effectively be managed by conventional polypectomy [4]. However, management of large colorectal polyps
(≥2cm) require more advanced resection techniques, as conventional snare-based
techniques might result in piecemeal resection, which precludes proper histopathological evaluation and increases the risk for recurrence [5]. Given that large polyps
may have an increased risk for harboring malignancy [6], adequate treatment is of
the utmost importance. Further, risks of different procedures should be considered.
Search Strategy
A comprehensive literature search of Cochrane Database of Collected Research,
EMBASE, and MEDLINE was performed. The search strategy included different
combinations of the following terms: “colon or colorectal”, “large polyp or polyp
≥2 cm”, “polypectomy”, “endoscopic mucosal resection (EMR)”, “endoscopic submucosal dissection (ESD)”, “surgery or colectomy”, “en-bloc resection”,
S. Yilmaz · E. Gorgun (*)
Department of Colorectal Surgery, Digestive Disease and Surgery Institute,
Cleveland, OH, USA
e-mail: gorgune@ccf.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_15
179
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Table 15.1 PICO table
Intervention
Patients
Patients with large (≥2
cm) colorectal polyps
ESD Endoscopic Submucosal Dissection, EMR Endoscopic Mucosal Resection, U-EMR
Underwater EMR
En-bloc resection: Resection of a neoplasm in one piece. R0 resection: En-bloc resection of a
lesion with histologically proven negative margins
groups Comparator groups
ESD Conventional
polypectomy
EMR
U-EMR
Hybrid ESD
Surgery
EMR Conventional
polypectomy
U-EMR
Hybrid ESD
Surgery
S. Yilmaz and E. Gorgun
Outcomes
Primary:
• Postoperative/procedural
complications
• En-bloc and R0
resection
• Local recurrence
Secondary:
• Procedure time
• Length of hospital stay
• Cost
“perforation”, “bleeding”, “recurrence” in “All elds”, and the related Mesh terms
to identify all English-language publications from 1999 (the year ESD was rst
described [7]) to 2022. Since guidelines’ recommendation is to use ESD for resection of polyps larger than 2cm [5, 8], ESD is identied as the intervention group,
and studies comparing ESD with any of the following were included: conventional
polypectomy (CP), EMR, Underwater EMR (U-EMR), Hybrid ESD, and surgery.
However, while conducting the search, studies comparing EMR with different techniques (other than ESD) were found. They were also included to give a more comprehensive information about efcacy and safety of different resection techniques.
Primary outcomes were: postoperative/procedural complications (mainly bleeding
and perforation), en-bloc resection, R0 resection, and tumor recurrence. Secondary
outcomes were: procedure time, length of hospital stay, and cost (Table 15.1).
Studies were excluded according to the following criteria: (a) Articles without a
control group (non-comparative studies); (b) Articles including patients with polyps
≤2cm without a subgroup analysis for patients with large polyps; (c) Conference
abstracts (since evaluation for quality of evidence would not be possible), systematic reviews, meta-analyses, guidelines, book chapters, editorials. Only the most
recent study was included in the presence of multiple articles reporting data from
the same study population. The references of the included studies were reviewed to
identify additional studies that were incorporated as appropriate.
Results
Colorectal ESD was rst described in 1999 [7]. Since then, literature on the outcomes of different management techniques for colorectal polyps has been expanding. Guidelines recommend CP and/or EMR for most supercial colorectal lesions
and ESD for lesions larger than 2cm and/or lesions with suspicion of submucosal
15 What Are theOptions forManagement ofLarge Colonic Polyps?
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invasion [5, 8]. However, reports published in this area are mostly case series (non-
comparative) and/or include polyps regardless of their size without a subgroup
analysis for large polyps.
12 studies comparing ESD with: CP&EMR [9], EMR [10–15], U-EMR [16],
Hybrid ESD [12, 17–19], and surgery [20] were identied and summarized in
Table15.2. 5 studies comparing EMR with: CP [21], U-EMR [22, 23], Hybrid ESD
[12], and surgery [24] were identied and summarized in Table15.3. 1 study [12]
was included in both tables, as it compared the outcomes of EMR, Hybrid ESD, and
ESD. Reports included: 2 randomized controlled trials (RCTs) [21, 22], 2 prospective cohort [9, 18] and 12 retrospective cohort studies [10–17, 19, 20, 23, 24].
181
En-Bloc, R0 andComplete Resection
In terms of efcacy of different techniques, most studies [9–14, 16–19, 22, 23]
reported en-bloc resection (resection of a neoplasm in one-piece) with some [10, 12,
14, 16–19] reporting R0 resection (en-bloc resection of a lesion with histologically
proven negative margins) rates. Oka etal. [9] combined CP with EMR and compared the en-bloc resection rate with ESD, and reported that ESD achieved signicantly higher en-bloc resection rates. Studies comparing ESD with EMR reported
signicantly higher en-bloc [11–14] and R0 [12, 14] resection rates with ESD.Iizuka
etal. [10] compared 38 ESDs with 83 EMRs and found no signicant difference
between en-bloc resection rates. However, R0 resection rate was signicantly higher
for ESD.Hybrid ESD achieved similar en-bloc and R0 resection rates with ESD in
2 studies [18, 19]; whereas in other 2 studies [12, 17], ESD achieved signicantly
higher en-bloc and R0 resection rates.
Chien etal. [23] compared EMR with U-EMR, and reported that there was no
statistically signicant difference in en-bloc resection rates. Lee etal. [12] reported
that Hybrid ESD achieved higher en-bloc and R0 resection rates when compared
with EMR.
2 studies [ 15, 21] reported complete resection as resection of a lesion with histologically proven negative margins (instead of resection of a lesion in one-piece
with negative margins). ESD achieved signicantly higher complete resection rate
when compared with EMR [15], as EMR with CP [21]. When EMR was compared
with U-EMR, there was no signicant difference in incomplete resection rates [22].
Postoperative/Procedural Complications
Regarding safety of different techniques, most commonly reported complications
were bleeding [9, 11–19, 22, 23] and perforation [9–19]. 5 studies [12, 14, 20, 22, 24]
reported total complication rates. Surgery was associated with higher complication
rates compared to EMR [24] and ESD [20]. Bleeding (either early or delayed) rates
were not different between different techniques in the majority of the studies [9, 11–
19, 22]. Oka etal. [9] reported no signicant differences between perforation rates of
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Quality of
evidence
Moderate
Low
Moderate
Low
S. Yilmaz and E. Gorgun
Low
NSNSp<0.00001
2.5% vs. 1.4%
Delayed bleeding
CP & EMR
p<0.01
p=0.056NSp<0.05
1.1% vs. 0.9%
95.0% vs. 53.2%
1.4% vs. 6.8%
8% vs. 1%
Perforation
En bloc resection
Recurrence
(1,029)
61% vs. 54%
En bloc resection
NSNSp<0.0001
58% vs. 37%
1.4% vs. 3.1%
6.2% vs. 1.3%
84% vs. 33%
R0 resection
Perforation
En bloc resection
p<0.0001
p<0.0001
p=0.024NSp<0.001
2% vs. 14%
108±71 vs. 29±25
11.5% vs. 5.7%
Recurrence
Procedure time, min
p<0.001
0.6% vs. 0%
8% vs. 0%
92.7% vs. 42.9%
Bleeding
Perforation
En bloc resection
p<0.001
p<0.001
NSNSp=0.048
87.6% vs. 32.9%
0.8% vs. 25.7%
11.5% vs. 15.9%
0.6% vs. 2.9%
8% vs. 2.9%
R0 resection
Recurrence
Complication (any)
Bleeding
PerforationEn bloc
(69)
p=0.004
p=0.006
NS
NS
p=0.04
92.7% vs. 65.2%
87.6% vs. 59.4%
0.8% vs. 3.1%
2.4% vs. 2.9%
5.9% vs. 0%
resection
R0 resection
Recurrence
Perforation
p<0.001
p=0.002
p<0.001
83.5% vs. 48.1%
1.2% vs. 15.4%
87.2±49.7 vs.
29.4±26.1
En bloc resection
Recurrence
Procedure time, min
Intervention
group Control Group Outcome measures Results Signicance
ESD dissection
(816)
Study Design
Cohort
Study
Table 15.2 Studies comparing ESD with other techniques
Oka 2015 [9] Prospective
ESD (38) EMR (83) Perforation
Retrospective
Iizuka 2009
ESD (145) EMR (228) Delayed bleeding
Cohort
[10]
Saito 2009 [11] Retrospective
Cohort
ESD (314) EMR (140) Complication (any)
Lee 2011 [12] Retrospective
Cohort
ESD (314) Hybrid ESD
ESD (85) EMR (104) Bleeding
Retrospective
Cohort
Tajika 2011
[13]
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Quality of
evidence
Low
NSNSNS
p<0.0001
p<0.0001
9.5% vs. 6.4%
3.8% vs. 4.1%
5.7% vs. 2.3%
87.3% vs. 26.3%
83.4% vs. 26.3%
Bleeding
Perforation
En bloc resection
R0 resection
p=0.026
7.6% vs. 15.2%
Recurrence
Low
p<0.0001
NSNSNS
2.2±1.79 vs.
0.97±1.32
19.1% vs. 12.4%
6.1% vs. 3.3%
Length of stay, days
Intraprocedural
bleeding
p<0.001
p<0.001
p<0.001NSp<0.001
2.6% vs. 4.9%
83.9% vs. 32.2%
0.5% vs. 7.1%
55.4±47.0 vs.
25.6±32.7
2.4±1.1 vs. 2.5±1.4
Delayed bleeding
Perforation
Complete resection
Recurrence
Procedure time, min
Length of stay, days
NS
1480.0±728.0 vs.
729.8±299.7
847.6±823.0 vs.
Cost (initial
resection), p<0.001
Cost (cumulative),
Low
NS
Signicant
N/A
2.7% vs. 5.4%
5.4% vs. 0%
871.9±994.4
p<0.001
99% vs. 61%
Perforation
En bloc resection
183
(continued)
N/ANSSignicant
89% vs. 34%
0% vs 0%
64.8 vs. 6.7
R0 resection
Recurrence
Procedure time, min
Intervention
group Control Group Outcome measures Results Signicance
ESD (157) EMR (217) Complication (any)
Study Design
Retrospective
Cohort
Study
Soliman 2018
[14]
piecemeal (115)
ESD (429) EMR –
Cohort
Ham 2019 [15] Retrospective
ESD (74) U-EMR (74) Delayed bleeding
Retrospective
Cohort
a
Inoue 2021
[16]
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Quality of
evidence
Low
Low
Low
S. Yilmaz and E. Gorgun
Low
NSNSNS
1% vs. 0%
Immediate bleeding
p<0.01
p<0.01
p=0.05
1% vs. 4%
6% vs. 2%
85% vs. 49%
73% vs. 43%
52±37 vs. 40±25
Delayed bleeding
Perforation
En bloc resection
R0 resection
Procedure time, min
(47)
NSNSNSNSp=0.005
3.2% vs. 2.9%
6.5% vs. 8.8%
100% vs. 94.1%
93.5% vs. 91.2%
40.6±22.1 vs.
27.4±12.7
Bleeding
Perforation
En bloc resection
R0 resection
Procedure time, min
(34)
NSNSNSNSp<0.001
1.0% vs. 2.9%
2.9% vs. 5.9%
100% vs. 94.1%
90.2% vs. 76.5%
45.6±30.1 vs.
12.7±7.0
Bleeding
Perforation
En bloc resection
R0 resection
Procedure time, min
(34)
p<0.001NSNS
p<0.001
13% vs. 15%
133±72.7 vs. 136±45
1.5±1.4 vs. 5.2±2.4
ESD/surgery: 60%
Procedure time, min
Length of stay, days
Cost
Intervention
group Control Group Outcome measures Results Signicance
ESD (141) Hybrid ESD
Study Design
Retrospective
Cohort
Study
Byeon 2011
Table 15.2 (continued)
[17]
ESD (36) Hybrid ESD
Cohort
Bae 2016 [18] Prospective
ESD (102) Hybrid ESD
Cohort
Yang 2017 [19] Retrospective
ESD (48) Surgery (48) Complication (any)
Retrospective
Cohort
Gamaleldin
2017 [20]
No information regarding the signicance level for perforation, en bloc and R0 resection rates, and procedure time
a
CP Conventional polypectomy, EMR Endoscopic mucosal resection, ESD Endoscopic submucosal dissection, NS Non-signicant, U-EMR Underwater EMR
En bloc resection: resection of a polyp in one-piece. R0 resection: resection of a polyp in one-piece with histologically proven negative margins. Complete
resection: resection of a polyp with histologically proven negative margins (not necessarily in one-piece)
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