Risk Factors for Stricture After Endoscopic Submucosal Dissection of Large Rectal Neoplasms.

Abstract

Background: While acute adverse events after endoscopic submucosal dissection, such as perforation and bleeding, are well-documented, studies on stricture are scarce.

Objective: This study aims to identify risk factors for rectal stricture and symptomatic stricture after endoscopic submucosal dissection, and to evaluate patient outcomes in a Western tertiary cancer center.

Design: Single-center retrospective study from a prospectively collected database of rectal endoscopic submucosal dissections.

Settings: Reference cancer center.

Patients: Patients undergoing endoscopic submucosal dissection for rectal neoplasms from July 2010 to January 2020. Exclusion criteria were incomplete resections, referral for low anterior resection, proximal diversions (symptomatic group), and loss to follow-up. A specific follow-up protocol was established for patients with lesions occupying more than 90% of the rectal circumference.

Interventions: Rectal strictures were classified as complete or partial.

Main outcomes measures: Assessment of risk factors for stricture after rectal endoscopic submucosal dissection.

Results: Of 109 rectal lesions resected, 94 cases were included. Twenty patients (21,3%) developed stricture (thirteen complete and seven partial stricture). Univariate analysis identified distance from the anal verge< 5 cm, larger size and circumferential mucosal defect >90% as significantly associated with stricture (p < 0.05). On multivariable analysis showed that only circumferential mucosal defect ≥90% was significantly associated with stricture (p < 0.001). None of the patients with partial stricture were symptomatic, while eleven out of thirteen with complete stricture were symptomatic. All symptomatic patients underwent serial dilations, with balloon or digitally, with symptom resolution within 1 to 8 months (mean of 7.8 sessions of dilation procedures).

Limitations: Single-center retrospective study.

Conclusions: Circumferential mucosal defect ≥90% was the only significant risk factor for stricture after extensive rectal endoscopic submucosal dissection procedures on multivariable analysis. All patients with symptomatic stricture were successfully treated with dilation sessions. See Video Abstract.