Endoscopic Mucosal Resection: First-Line Treatment for Laterally Spreading Lesions at Anorectal Junction
Douglas K. Rex, MD, FASGE reviewing Shahidi N, et al. Gut 2019 Nov 12.
Laterally spreading lesions at the anorectal junction can be treated by endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or transanal surgical resection. In a study of 100 EMRs of anorectal junction lesions (distal margin, ≤20 mm from the dentate line) compared to rectal lesions (distal margin, >20 mm from the dentate line), technical success of EMR was 98%, recurrence rates were low and not different for anorectal versus rectal lesions, delayed hemorrhage occurred in 11.1% of the anorectal lesions, and submucosal cancer was identified in 3% of the patients.
COMMENT
Other factors being equal, the rectum is an attractive site for ESD compared to EMR because it allows for accurate identification of superficial submucosal invasion, which can be considered curative after en bloc endoscopic resection. This study argues that EMR is a reasonable choice for most lesions at the anorectal junction because the incidence of cancer was only 3%, making the number needed to treat by ESD to avoid one surgery at least 30. Thus, selective application of ESD seems a reasonable policy, even for rectal lesions. This group has emphasized several unique features of anorectal junction lesions, including an increased incidence of severe post-procedural pain, for which they used local anesthetic in the submucosal injection fluid, and an increased incidence of bacteremia, for which prophylactic antibiotics were prescribed.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Douglas K. Rex, MD, FASGE
CITATION(S)
Shahidi N, Sidhu M, Vosko S, et al. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2019 Nov 12. (Epub ahead of print) (https://doi.org/10.1136/gutjnl-2019-319785)
