Endoscopic submucosal dissection for superficial ultra-low rectal tumors: outcomes and predictive factors for procedure difficulty

Yinxin Wu; Yanqin Xu; Haiyan Lin; Xiaolu Lin; Wanyin Deng; Wei Liang; Qing Lin

doi:10.62347/PVVD6843

Endoscopic submucosal dissection for superficial ultra-low rectal tumors: outcomes and predictive factors for procedure difficulty

Am J Cancer Res. 2024 Dec 15;14(12):5784-5797. doi: 10.62347/PVVD6843. eCollection 2024.

Authors

Yinxin Wu¹, Yanqin Xu¹, Haiyan Lin¹, Xiaolu Lin¹, Wanyin Deng¹, Wei Liang¹, Qing Lin²

Affiliations

¹ Department of Digestive Endoscopy, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University Fuzhou 350001, Fujian, China.
² Department of Ultrasound, The Second People's Hospital, Fujian University of Traditional Chinese Medicine Fuzhou 350003, Fujian, China.

Abstract

Background: Ultra-low rectal endoscopic submucosal dissection (ESD) presents technical challenges due to anatomical features. The objective of this research was to determine the risk factors linked to unsuccessful curative resections and to create a nomogram predictive model to assess the likelihood of encountering technical challenges.

Methods: Patients with ultra-low rectal tumors received ESD form June 2017 to December 2022 were retrospectively enrolled. An ESD procedure exceeding 30 min was deemed difficult. A logistic regression analysis was performed to pinpoint important factors and predictors. The effectiveness of the nomogram, which incorporated the identified predictors, was evaluated by employing receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).

Results: A total of 300 patients with ultra-low rectal tumors were enrolled, with a curative resection rate of 82.0%. Multivariate logistic regression revealed that poor lifting sign (OR = 3.282, P = 0.026), non-granular type laterally spreading tumors (LST-NG, OR = 2.230, P = 0.042) and procedure time ≥ 60 min (OR = 6.976, P = 0.010) contributed to non-curative resection. Predictors for ESD difficulty included tumor diameter ≥ 30 mm (compared with < 30 mm, 30-50 mm, OR = 2.450, P = 0.044; ≥ 50 mm, OR = 5.047, P = 0.009), ≥ 1/2 circumference involvement (OR = 3.183, P = 0.038); dentate line invasion (OR = 3.881, P = 0.026) and less colorectal ESD experience (OR = 3.415, P = 0.032). The nomogram performed well in both train and validation sets (area under the curve (AUC) = 0.873 and 0.810, respectively). Calibration plots exhibited satisfactory agreement between predicted and observed outcomes, and DCA showed superior clinical benefit of the model than individual predictors.

Conclusions: Poor lifting sign, LST-NG and procedure time ≥ 60 min were associated with non-curative resection for ultra-low rectal ESD. By including factors such as tumor size, location, and the operator's experience with ESD, the nomogram can predict the complexity of the procedure before surgery.

Keywords: Ultra-low rectal tumor; endoscopic submucosal dissection; nomogram; non-curative resection; technical difficulty.