What are the different surgical approaches for treating colonic dysplasia?

From the Guidelines

Surgical approaches for treating colonic dysplasia include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and colectomy, with the choice of approach depending on the size, location, and histological grade of the dysplasia, as well as patient factors such as comorbidities and disease history, as recommended by the most recent guidelines 1. The different types of surgery for colonic dysplasia can be categorized based on the size and characteristics of the lesion.

• For small, flat lesions, EMR is often appropriate, involving the injection of fluid beneath the dysplastic tissue and removal with a snare 1.
• ESD allows for en bloc removal of larger lesions by dissecting through the submucosal layer using specialized knives, and is considered for lesions that are clearly delineated without stigmata of invasive cancer or significant submucosal fibrosis 1.
• For extensive or multifocal dysplasia, particularly in conditions like inflammatory bowel disease, segmental or total colectomy may be necessary, especially if there is a finding of unresectable visible dysplasia or of invisible multifocal or high-grade dysplasia on histology 1. The management of colonic dysplasia also involves post-procedure surveillance, with follow-up colonoscopies typically recommended at intervals of 3-6 months initially, then annually if no recurrence is detected, as outlined in the guidelines 1. It is essential to consider the potential complications of these procedures, including bleeding, perforation, and incomplete resection, which occur in approximately 1-2% of endoscopic procedures, and to inform patients about these risks 1. The decision to proceed with a particular surgical approach should be made on a case-by-case basis, taking into account the individual patient's factors and the characteristics of the lesion, and considering referral to a specialized endoscopist or inflammatory bowel disease center if the resectability of a lesion is in question 1.

From the Research

Surgical Approaches for Colonic Dysplasia

The treatment of colonic dysplasia involves various surgical approaches, depending on the severity and location of the dysplastic lesions. The following are some of the surgical options:

• Total proctocolectomy: This is a historical approach that involves the removal of the entire colon and rectum 2.
• Segmental resection: This involves the removal of the affected segment of the colon, and is considered a definitive surgery for patients with chronic colitis and localized colorectal neoplasia 2.
• Subtotal colectomy: This involves the removal of a portion of the colon, and is considered an alternative to total proctocolectomy 2.
• Endoscopic resection: This involves the removal of dysplastic lesions using an endoscope, and is considered a safe and effective approach for patients with nonpolypoid dysplastic lesions 3, 4.
• Proctocolectomy with ileal pouch-anal anastomosis: This involves the removal of the colon and rectum, and the creation of an ileal pouch to connect the small intestine to the anus 5.

Indications for Surgery

Surgery is typically considered for patients with colonic dysplasia who have:

• High-grade dysplasia or cancer 5, 6
• Multifocal low-grade dysplasia 6
• Endoscopically unresectable lesions 5, 6
• Flat or invisible dysplasia 6

Considerations for Surgical Approach

The choice of surgical approach depends on various factors, including:

• Location and severity of the dysplastic lesions 2, 5
• Patient's overall health and medical history 2, 5
• Presence of other conditions, such as inflammatory bowel disease 2, 5
• Patient's preferences and quality of life considerations 2, 5