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Saudi J Gastroenterol
Saudi J Gastroenterol
SJG
Saudi J Gastroenterol
Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association
1319-3767
1998-4049
Wolters Kluwer - Medknow India

39044619
SJG-30-198
10.4103/sjg.sjg_238_24
Editorial
Risk of perforation related to colorectal endoscopic submucosal dissection: Is this finally predictable?
Murino Alberto 12
Rimondi Alessandro 1
1 Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
2 Department of Gastroenterology, Cleveland Clinic London, London, UK
Address for correspondence: Dr. Alberto Murino, Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London, Pond Street, London, NW3 2QG, UK. E-mail: a.murino@nhs.net
Jul-Aug 2024
24 7 2024
30 4 198199
Copyright: © 2024 Saudi Journal of Gastroenterology
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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pmcOver the past decade, endoscopic submucosal dissection (ESD) has spread through Western countries and has become a more available technique for the resection of colorectal lesions. A recent survey of the medical literature ranked this topic among the top ten most published subjects.[1] While interest and access to ESD are increasing worldwide, the technique’s learning curve remains prolonged,[234] needing comprehensive training and supervision, as recommended by international guidelines.[56]

Among the few potential complications related to ESD, perforation remains the most serious. It is directly related to the endoscopic procedure, and if not promptly recognized and managed endoscopically, it would be likely to require surgical intervention, necessitating prolonged hospital stays and, in rare cases, impacting patients’ quality of life, when a temporary stoma is required.[7]

Although previous reports indicated a perforation risk ranging from 1.4% to 20.4%, these data are based on studies published between 2007 and 2012, when ESD was available only in a few selected centers, primarily in East Asia. Additionally, the ESD techniques of that era were limited to conventional methods. Today, ESD strategies can be tailored using the pocket creation method (PCM), saline immersion therapeutic endoscopy, or traction techniques, depending on the lesion’s nature and location. Moreover, the range of endoscopic devices has significantly expanded, including various ESD knives, clips, and injecting agents. Consequently, the ESD perforation rate has decreased over the past decade not only in Eastern countries but also in Western nations.[56] It would be difficult to imagine strong international endorsement from national and international societies for a technique with a perforation risk as high as 20%.

Numerous studies have sought to identify risk factors associated with increased technical difficulties. Notably, a comprehensive meta-analysis by Santos et al.[8] (2021) synthesized the outcomes of 22 studies and identified fibrosis, right colon location, and larger size (>20 mm) as risk factors for colonic perforations, whereas endoscopist experience served as a protective factor.

Similarly, a retrospective multicenter study by Kamigaichi et al.[9] involving 2,423 patients undergoing ESD for colorectal tumors identified submucosal fibrosis, poor scope operability, procedure time, and tumor size (>40 mm) as perforation risk factors.

Zhang et al.[10] have commendably contributed to this body of literature by identifying factors potentially linked to colonic perforation. The predictive nomogram they developed offers endoscopists a straightforward tool for determining the best treatment approach for colorectal lesions, which could be integrated especially in the setting of multidisciplinary team meetings.

This study reinforces previously identified technical challenges in ESD, with some modifications. For example, the nomogram does not consider operator experience as a predictor for perforation, despite its extensive documentation in ESD learning curves.[11] The authors attribute this to different case selections between inexperienced and experienced operators. However, the authors did not specify the number of cases required to be considered an experienced operator. This is a crucial aspect as it is generally advocated that between 200 and 250 cases are needed to master the technique.

The factors linked to perforation are also those requiring advanced endoscopic skills and consequently are associated with prolonged procedure times. A recent model developed by a Dutch research group considered lesion morphology, luminal circumference, the presence of depressed areas, tumor size, and operator experience to predict procedure time.[12]

Interestingly, the study also identifies left colon location as a potential risk factor for perforation, contrary to prior literature that highlighted the right colon’s thinner muscle layer as a risk factor.[8] These slight deviations from existing publications likely reflect differences in practices and case mixes among centers. In this specific study, up to 14.2% of the lesions removed were sessile serrated lesions, which are typically shallower, located in the right colon, and easier to lift.

Such deviations underscore the challenge of summarizing varied practices with a simple nomogram, without external validation. With the availability of user-friendly software enabling complex calculations, it is crucial to seek external validation in diverse centers and scenarios. This ensures that the model does not suffer from overfitting bias, where it predicts the outcomes accurately in one hospital but fails in another.

In conclusion, Zhang et al. should be praised for providing a simple nomogram to predict perforation risk during colorectal ESD. While it holds promise for daily practice, validation in other centers is necessary to fully understand its performance.
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