Review for 10.1186/1471-230X-10-135 (2010)

Reviewer's report
Title:Giant flat adenomas of rectum successfully treated in two steps by
endoscopic submucosal dissection and endoscopic mucosal resection.
Version: 1Date:24 February 2010
Reviewer: Yutaka Saito
Reviewer's report:
I read this case series with interest but there are some limitations for
publications.
First of all, this combined technique will be applicable for relatively small LSTs
(2cm-4cm) but LSTs more than 5cm is difficult treat by this technique.
Even using combined ESD/EMR, there should be local recurrences after
piecemeal resections and there is a risk of overlooking sm-deep invasion or
lymph-vascular invasions.
Please use the terminology of “LST” but “giant flat adenoma” because LST is well
know terminology.
The conclusion should be changed. It is difficult to say this conclusion from this
limited experiences.
ABSTRACT
still, ESD en bloc resections of huge lesions are associated with increased
complications.
Comment) This demands mainly on the endoscopists skill and complications can
be reduced by the learning curve.
RESULTS In all three patients we obtained the complete dissection of the polyp
and the complete histological evaluation in absence of complications and
recurrence at 6 months’
follow up.
The total number of three cases were too small to discuss about the recurrence
rate.
If the lesion resected by piecemeal, the recurrence rate should be raised even by
combined ESD methods as authors mentioned as follows;
CONCLUSIONS: To confirm our results, larger trials with longer follow up are
required together with improvement of the technique and of the technical
devices.
CASE REPORTS
technique, patients were followed up at 3, 6 and 12 months for the first year then
they were followed once a year.
Patient 1
The ESD/EMR combined procedure was carried out using a double-channel
colonoscope (Olympus CF2T160I, Olympus Italia, Milan, Italy) with the patient
deeply sedated by propofol. Given the position and size of the lesion, a
gastroscope (Olympus Gif Q 165, Olympus Italia, Milan, Italy) retroflexed into the
colon was used to resect the distal margin of the polyp.
Q) Why the patients deeply sedated? I think colorectal ESD needs patients
position change, so deep sedation is not recommended.
stained with 1% indigo carmine (Figure 1b),
Comment) Indigo-carmine is not a staining method but just contrast methods, so
please use “spray” but “stain”.
Q) How many pieces resections were needed on this lesion?
Patient 2
Again, indigocarmine was not a staining method.
Patient 3
Comment) There is evidence that recurrence rate will depend on the number of
resection pieces, so please clarify the number of resection in each cases.
DISCUSSION
In all patients of our series ESD was planned, given the lesion size and depth.
After the excision of the external part, we were unable to reach the centre of the
polyps removing the lesions en bloc (21). This is due to the limited vision of the
cutting area for huge lesions with difficulty in assessing the correct deeper
submucosal tissue plane during the resection from the margins to the centre of
the lesion.
Comment) Even for large lesions, direct visualization of the cutting line is
possible if you use patients position change to use the gravity of the resected
specimen.
In order to use the gravity, it is not recommended to use deep sedation for
colorectal ESD.
So, the conclusion should be changed. It is difficult to say this conclusion from
this limited experiences.
Level of interest: An article of limited interest
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.