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Endoscopic submucosal dissection for anorectal tumor with hemorrhoids close to the dentate line: a multicenter study of Hiroshima GI Endoscopy Study Group



The lower rectum close to the dentate line has distinct characteristics, making endoscopic submucosal dissection (ESD) of tumors challenging. We assessed clinical outcomes of ESD for such patients with hemorrhoids.


Sixty-four patients (mean age, 68 years) underwent ESD for anorectal tumors close to the dentate line. We divided patients into those with (Group A, 45 patients) and without hemorrhoids (Group B, 19 patients). We examined en bloc and histological en bloc resection rates, procedure time, complication rates, and postoperative prognosis after ESD.


The mean tumor size was 43 mm. Histologic diagnoses were adenoma (42 %, 27/64), carcinoma in situ (44 %, 28/64), and T1 carcinoma (14 %, 9/64). There was no significant difference in en bloc resection (93 %, 42/45 vs. 95 %, 18/19) or postoperative bleeding rates (16 %, 7/45 vs. 11 %, 2/19) between Groups A and B, respectively. The mean procedural durations were 120 and 124 min, respectively, in Groups A and B. No perforations occurred. There was no significant difference in postoperative anal pain rate between Groups A (18 %, 8/45) and B (16 %, 3/19), and it resolved within a few days in all cases. There was one case of stricture in Group B. Two patients with T1 carcinoma underwent additional surgery, one underwent chemotherapy, and five had no additional treatment. No recurrence occurred during the follow-up period of 38 months.


ESD is safe and effective for anorectal tumors close to the dentate line in patients with hemorrhoids.

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  1. 1.

    Tanaka S, Oka S, Chayama K (2008) Colorectal endoscopic submucosal dissection: present status and future perspective, including its differentiation from endoscopic mucosal resection. J Gastroenterol 43:641–651

  2. 2.

    Oka S, Tanaka S, Saito Y, Iishi H, Kudo SE, Ikematsu H, Igarashi M, Saitoh Y, Inoue Y, Kobayashi K, Hisabe T, Tsuruta O, Sano Y, Yamano H, Shimizu S, Yahagi N, Watanabe T, Nakamura H, Fujii T, Ishikawa H, Sugihara K, Colorectal Endoscopic Resection Standardization Implementation Working Group of the Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan (2015) Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 110:697–707

  3. 3.

    Standring S (2008) Gray’s anatomy: the anatomical basis of clinical practice. Churchill Livingstone, London

  4. 4.

    Duthie HL, Gairns FW (1960) Sensory nerve-endings and sensation in the anal region of man. Br J Surg 47:585–595

  5. 5.

    Johanson JF, Sonnenberg A (1990) The prevalence of hemorrhoids and chronic constipation: an epidemiologic study. Gastroenterology 98:380–386

  6. 6.

    Sneider EB, Maykel JA (2010) Diagnosis and management of symptomatic hemorrhoids. Surg Clin N Am 90:17–32

  7. 7.

    Su MY, Chiu CT, Wu CS, Ho YP, Lien JM, Tung SY, Chen PC (2003) Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids. Gastrointest Endosc 58:871–874

  8. 8.

    Kantsevoy SV, Bitner M (2013) Nonsurgical treatment of actively bleeding internal hemorrhoids with a novel endoscopic device (with video). Gastrointest Endosc 78:649–653

  9. 9.

    Nakadoi K, Tanaka S, Hayashi N, Ozawa S, Terasaki M, Takata S, Kanao H, Oka S, Chayama K (2012) Clinical outcomes of endoscopic submucosal dissection for rectal tumor close to the dentate line. Gastrointest Endosc 76:444–450

  10. 10.

    Imai K, Hotta K, Yamaguchi Y, Shinohara T, Ooka S, Shinoki K, Kakushima N, Tanaka M, Takizawa K, Matsubayashi H, Oishi T, Ono H (2014) Safety and efficacy of endoscopic submucosal dissection of rectal tumors extending to the dentate line. Endoscopy 47:529–532

  11. 11.

    Sánchez-Yagüe A, Yamaguchi Y, Takao T, Tanaka M, Kakushima N, Takizawa K, Ikehara H, Matsubayashi H, Ono H (2011) Endoscopic submucosal dissection of a lower rectal polyp proximal to the dentate line by using local lidocaine injection. Gastrointest Endosc 73:405–407

  12. 12.

    Antillon MR, Bartalos CR, Miller ML, Diaz-Arias AA, Ibdah JA, Marshall JB (2008) En bloc endoscopic submucosal dissection of a 14-cm laterally spreading adenoma of the rectum with involvement to the anal canal: expanding the frontiers of endoscopic surgery (with video). Gastrointest Endosc 67:332–337

  13. 13.

    Tamaru Y, Oka S, Tanaka S, Ninomiya Y, Asayama N, Shigita K, Nishiyama S, Hayashi N, Arihiro K, Chayama K (2015) Early squamous cell carcinoma in the anal canal resected by endoscopic submucosal dissection. Case Rep Gastroenterol 9:120–125

  14. 14.

    Fujimoto K, Fujishiro M, Kato M, Higuchi K, Iwakiri R, Sakamoto C, Uchiyama S, Kashiwagi A, Ogawa H, Murakami K, Mine T, Yoshino J, Kinoshita Y, Ichinose M, Matsui T (2014) Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc 26:1–14

  15. 15.

    Tanaka S, Tamegai Y, Tsuda S, Saito Y, Yahagi N, Yamano HO (2010) Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig Endosc 22:S2–S8

  16. 16.

    Tanaka S, Kashida H, Saito Y, Yahagi N, Yamano H, Saito S, Hisabe T, Yao T, Watanabe M, Yoshida M, Kudo SE, Tsuruta O, Sugihara K, Watanabe T, Saitoh Y, Igarashi M, Toyonaga T, Ajioka Y, Ichinose M, Matsui T, Sugita A, Sugano K, Fujimoto K, Tajiri H (2015) JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 27:417–434

  17. 17.

    Oba S, Tanaka S, Oka S, Kanao H, Yoshida S, Shimamoto F, Chayama K (2010) Characterization of colorectal tumors using narrow-band imaging magnification: combined diagnosis with both pit pattern and microvessel features. Scand J Gastroenterol 45:1084–1092

  18. 18.

    Tajiri H, Kitano S (2004) Complications associated with endoscopic mucosal resection: definition of bleeding that can be viewed as accidental. Dig Endosc 16:S134–S136

  19. 19.

    Japanese Society for Cancer of the Colon and Rectum (JSCCR) (2014) JSCCR guidelines for the treatment of colorectal carcinoma. Kanehara Shuppan Co., Tokyo (in Japanese)

  20. 20.

    Matsumoto A, Tanaka S, Oba S, Kanao H, Oka S, Yoshihara M, Chayama K (2010) Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 45:1329–1337

  21. 21.

    Goligher JC, Leacock AG, Brossy JJ (1955) The surgical anatomy of the anal canal. Br J Surg 43:51–61

  22. 22.

    Uraoka T, Saito Y, Matsuda T, Ikehara H, Gotoda T, Saito D, Fujii T (2006) Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut 55:1592–1597

  23. 23.

    Terasaki M, Tanaka S, Shigita K, Asayama N, Nishiyama S, Hayashi N, Nakadoi K, Oka S, Chayama K (2014) Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms. Int J Colorectal Dis 29:877–882

  24. 24.

    Ninomiya Y, Oka S, Tanaka S, Nishiyama S, Tamaru Y, Asayama N, Shigita K, Hayashi N, Chayama K (2015) Risk of bleeding after endoscopic submucosal dissection for colorectal tumors in patients with continued use of low-dose aspirin. J Gastroenterol 50:1041–1046

  25. 25.

    Barker JA, Hill J (2011) Incidence, treatment and outcome of rectal stenosis following transanal endoscopic microsurgery. Tech Coloproctol 15:281–284

  26. 26.

    Bretagnol F, Merrie A, George B, Warren BF, Mortensen NJ (2007) Local excision of rectal tumours by transanal endoscopic microsurgery. Br J Surg 94:627–633

  27. 27.

    Kochhar R, Makharia GK (2002) Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 56:829–834

  28. 28.

    Yamaguchi N, Isomoto H, Nakayama T, Hayashi T, Nishiyama H, Ohnita K, Takeshima F, Shikuwa S, Kohno S, Nakao K (2011) Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Gastrointest Endosc 73:1115–1121

  29. 29.

    Lee M, Kubik CM, Polhamus CD, Brady CE III, Kadakia SC (1995) Preliminary experience with endoscopic intralesional steroid injection therapy for refractory upper gastrointestinal strictures. Gastrointest Endosc 41:598–601

  30. 30.

    Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, Kikuchi T, Fu KI, Sano Y, Saito D (2007) Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 66:966–973

  31. 31.

    Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, Yoshida S, Chayama K (2007) Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 66:100–107

  32. 32.

    Toyonaga T, Man-i M, Fujita T, East JE, Nishino E, Ono W, Morita Y, Sanuki T, Yoshida M, Kutsumi H, Inokuchi H, Azuma T (2010) Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum. Endoscopy 43:714–722

  33. 33.

    Hayashi N, Tanaka S, Nishiyama S, Terasaki M, Nakadoi K, Oka S, Yoshihara M, Chayama K (2014) Predictors of incomplete resection and perforation associated with endoscopic submucosal dissection for colorectal tumors. Gastrointest Endosc 79:427–435

  34. 34.

    Tanaka S, Terasaki M, Kanao H, Oka S, Chayama K (2012) Current status and future perspectives of endoscopic submucosal dissection for colorectal tumors. Dig Endosc 24:S73–S79

  35. 35.

    Veltcamp Helbach M, Deijen CL, Velthuis S, Bonjer HJ, Tuynman JB, Sietses C (2015) Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases. Surg Endosc. doi:10.1007/s00464-015-4221-y

  36. 36.

    Kawaguti FS, Nahas CS, Marques CF, Martins BC, Retes FA, Medeiros RS, Hayashi T, Wada Y, de Lima MS, Uemura RS, Nahas SC, Kudo SE, Maluf-Filho F (2014) Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer. Surg Endosc 28:1173–1179

  37. 37.

    Park SU, Min YW, Shin JU, Choi JH, Kim YH, Kim JJ, Cho YB, Kim HC, Yun SH, Lee WY, Chun HK, Chang DK (2012) Endoscopic submucosal dissection or transanal endoscopic microsurgery for nonpolypoid rectal high grade dysplasia and submucosa-invading rectal cancer. Endoscopy 44:1031–1036

  38. 38.

    Guerrieri M, Baldarelli M, de Sanctis A, Campagnacci R, Rimini M, Lezoche E (2010) Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience. Surg Endosc 24:445–449

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This study was conducted with a Grant-in-Aid from the Japan Agency for Medical Research and Development, AMED (15ck0106102h0102).

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Correspondence to Shiro Oka.

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Yuzuru Tamaru, Shiro Oka, Shinji Tanaka, Yuko Hiraga, Masaki Kunihiro, Shinji Nagata, Akira Furudoi, Yuki Ninomiya, Naoki Asayama, Kenjiro Shigita, Soki Nishiyama, Nana Hayashi, and Kazuaki Chayama have no conflicts of interest or financial ties to disclose.

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Tamaru, Y., Oka, S., Tanaka, S. et al. Endoscopic submucosal dissection for anorectal tumor with hemorrhoids close to the dentate line: a multicenter study of Hiroshima GI Endoscopy Study Group. Surg Endosc 30, 4425–4431 (2016). https://doi.org/10.1007/s00464-016-4761-9

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  • Endoscopic submucosal dissection
  • Rectal tumor
  • Dentate line
  • Hemorrhoid