Is Endoscopic Submucosal Dissection (ESD) Ready to Enter Center-Stage for the Resection of Large Colorectal Polyps?

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Endoscopic submucosal dissection (ESD) is a treatment for superficial tumors, pre-cancerous, and early cancerous lesions in the gaintestinal (GI) tract [1, 2]. This endoscopically-guided minimal invasive, surgical technique was first developed in Japan back in the late 1990s [3, 4]. However, the initial concept of endoscopic removal of colorectal polyps dates back to 1971 when Dehyle et al. reported on using a novel diathermy snare [5]. Soon thereafter, Dehyle et al reported on the concept of resection of sessile colon polyps after creating a submucosal cushion with injection [6]. The concept of advanced endoscopic mucosal resection (EMR) was born. Interestingly, the reason for introducing injection-assisted polypectomy was to prevent colon perforations, which were happening quite often at that time using standard snare resection techniques [6]. Thus, a concept introduced to prevent colon perforation became a method to increase the chances of in-toto and R0 resection. Later on, submucosal injection became the basis of EMR, ESD, tunneling and third-space techniques.

Despite the advantages of ESD over other resection techniques for early colon neoplasia, this technique has been slow to enter clinical practice in many parts of the world. Whereas technical factors and acquisition of skills may be one reason for this, a big argument still hindering its more widespread acceptance was the lack of large, prospective observational outcome studies.

The solution to this knowledge gap is provided now by the Colorectal ESD Activation Team of Japan (CREATE-J), consisting of 20 academic or tertiary institutions in Japan [7]. CREATE-J designed a prospective, large-scale, multicenter cohort trial of colorectal ESD to address this aspect in an elegant and overwhelming study, enrolling 1740 consecutive patients 1814 colorectal epithelial neoplasms ≥ 20 mm who underwent ESD between February 2013 and January 2015. The patients were followed intensively during a 5-year follow-up. In the 1814 cases, the mean tumor diameter was 32.4 mm, and more than half of the lesions (55.5%) were located in the right colon. Most tumors (n=1612), 88.9% were LST. En bloc resection was achieved in 1759 (97.0%) lesions, whereas piecemeal resection was required in 35 (1.9 %) lesions. Only twenty (1.1%) ESD procedures were discontinued due to technical difficulties or severe intraoperative adverse events. The 5-year OS, DSS, and intestinal preservation rates were 93.6%, 99.6%, and 88.6%, respectively. The authors concluded that a favorable long-term prognosis indicates that ESD can be the standard treatment for large colorectal epithelial neoplasms (7).

In summary, this seminal study has shown that ESD is safe and efficient to resect advanced colonic neoplastic lesions, with low complication rates and excellent long-term outcomes. The authors placed the finger in the wound and showed us that ESD is should probably the standard of care for dealing with larger colorectal lesions.

How does this study affect our practice?

It is evident that ESD is an efficient technique to achieve complete resection of large colorectal lesions. Second, the favorable results a very large, prospective follow-up study now underscore the clinical efficacy of this resection method. Based on this findings, it is our opinion that ESD or hybrid ESD-EMR should be considered the key standard for resection of larger colorectal lesions. Ideally, a prospective, randomized study comparing ESD to piecemeal-EMR should be performed.

Happy to take questions on this study in the comments section below

References:

1.    Saito Y, Fujii T, Kondo H, et al. Endoscopic treatment for laterally spreading tumors in the colon. Endoscopy. 2001;33(8):682–686.

2.    Bhatt A, Abe S, Kumaravel A, Vargo J, Saito Y. Indications and Techniques for Endoscopic Submucosal Dissection. Am J Gastroenterol. 2015;110:784-91.

3.    Lee EJ, Lee JB, Lee SH, et al. Endoscopic submucosal dissection for colorectal tumors--1,000 colorectal ESD cases: one specialized institute's experiences. Surg Endosc 2013;27:31-9.

4.    Yamada M, Saito Y, Takamaru H, et al. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017;49:233-242.

5.    Deyhle P, Seuberth K, Jenny S et al. Endoscopic polypectomy in the proximal colon. Endoscopy 1971; 3: 103 – 105

6.    Dehyle P, Largiadér F, Jenny S, Fumagalli I. A method for endoscopic electroresection of sessile colonic polyps. Endoscopy 1973;5:38-40.

7.    Ohata K, Kobayashi N, Sakai E, et al. Long-Term Outcomes After Endoscopic Submucosal Dissection for Large Colorectal Epithelial Neoplasms: A Prospective, Multicenter, Cohort Trial from Japan. Gastroenterology. 2022 Jul 8:S0016-5085(22)00751-X. doi: 10.1053/j.gastro.2022.07.002. Epub ahead of print. PMID: 35810779.