EMR Versus ESD: Pros and Cons

  • Fayez Sarkis
  • Vijay Kanakadandi
  • Mojtaba S. Olyaee
  • Amit RastogiEmail author


The two techniques for removal of large colonic polyps are endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). While EMR is easier to learn and perform, has a lower risk of adverse events, and carries a lower-cost burden, ESD is associated with lower risk of recurrence and may obviate the need for surgery in a subset of lesions with early invasive cancer. However, Western endoscopists have limited experience with ESD, and there is no reimbursement for this procedure in the USA. Therefore, there is limited incentive to learn and perform this more complex and higher-risk procedure by Western endoscopists. EMR therefore continues to be the more commonly performed endoscopic resection procedure. Here we discuss the advantages and disadvantages of the EMR vs. ESD and their role in the management of large colon polyps. Furthermore, we also discuss the pros and cons of ESD versus EMR in early squamous esophageal cancer, early Barrett’s-related esophageal cancer, and early gastric cancer.


Adenoma Endoscopic mucosal resection Endoscopic submucosal dissection R0 resection Colonoscopy Advanced adenoma, Barrett’s esophagus, Squamous cell cancer, Gastric cancer 


  1. 1.
    Stryker SJ, et al. Natural history of untreated colonic polyps. Gastroenterology. 1987;93(5):1009–13.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Jayanna M, et al. Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions. Clin Gastroenterol Hepatol. 2016;14(2):271–8 e1-2.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Ahlenstiel G, et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc. 2014;80(4):668–76.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Mounzer R, et al. Endoscopic and surgical treatment of malignant colorectal polyps: a population-based comparative study. Gastrointest Endosc. 2015;81(3):733–740 e2.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Hermanek P, Gall FP. Early (microinvasive) colorectal carcinoma. Pathology, diagnosis, surgical treatment. Int J Color Dis. 1986;1(2):79–84.CrossRefGoogle Scholar
  6. 6.
    Arezzo A, et al. Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United European Gastroenterol J. 2016;4(1):18–29.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Fujiya M, et al. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc. 2015;81(3):583–95.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Moss A, et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut. 2015;64(1):57–65.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Bosch SL, et al. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions. Endoscopy. 2013;45(10):827–34.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Pimentel-Nunes P, et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2015;47(9):829–54.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Burgess NG, et al. Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology. 2017;153(3):732–742 e1.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Bahin FF, et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut. 2018;67(11):1965–73.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Fuccio L, et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc. 2017;86(1):74–86 e17.PubMedCrossRefGoogle Scholar
  14. 14.
    Chung IK, et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc. 2009;69(7):1228–35.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Iacopini F, et al. Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves. Gastrointest Endosc. 2012;76(6):1188–96.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Probst A, et al. Endoscopic submucosal dissection in large sessile lesions of the rectosigmoid: learning curve in a European center. Endoscopy. 2012;44(7):660–7.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Hotta K, et al. A comparison of outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasms between high-volume and low-volume centers: multi-center retrospective questionnaire study conducted by the Nagano ESD Study Group. Intern Med. 2010;49(4):253–9.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Heitman SJ, Bourke MJ. Endoscopic submucosal dissection and EMR for large colorectal polyps: "the perfect is the enemy of good". Gastrointest Endosc. 2017;86(1):87–9.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Rex DK, Hassan C, Dewitt JM. Colorectal endoscopic submucosal dissection in the United States: why do we hear so much about it and do so little of it? Gastrointest Endosc. 2017;85(3):554–8.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Pennathur A, et al. Oesophageal carcinoma. Lancet. 2013;381(9864):400–12.PubMedCrossRefGoogle Scholar
  21. 21.
    Lao-Sirieix P, Fitzgerald RC. Screening for oesophageal cancer. Nat Rev Clin Oncol. 2012;9(5):278–87.PubMedCrossRefGoogle Scholar
  22. 22.
    Scholvinck DW, et al. Detection of lesions in dysplastic Barrett’s esophagus by community and expert endoscopists. Endoscopy. 2017;49(2):113–20.PubMedGoogle Scholar
  23. 23.
    Buttar NS, et al. Extent of high-grade dysplasia in Barrett’s esophagus correlates with risk of adenocarcinoma. Gastroenterology. 2001;120(7):1630–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Sharma P. Clinical practice. Barrett’s esophagus. N Engl J Med. 2009;361(26):2548–56.PubMedCrossRefGoogle Scholar
  25. 25.
    Weston AP, et al. Long-term follow-up of Barrett’s high-grade dysplasia. Am J Gastroenterol. 2000;95(8):1888–93.PubMedCrossRefGoogle Scholar
  26. 26.
    Pech O, et al. Prospective evaluation of the macroscopic types and location of early Barrett’s neoplasia in 380 lesions. Endoscopy. 2007;39(7):588–93.PubMedCrossRefGoogle Scholar
  27. 27.
    Alvarez Herrero L, et al. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy. 2010;42(12):1030–6.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Manner H, et al. Early Barrett’s carcinoma with “low-risk” submucosal invasion: long-term results of endoscopic resection with a curative intent. Am J Gastroenterol. 2008;103(10):2589–97.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Wheeler JB, Reed CE. Epidemiology of esophageal cancer. Surg Clin North Am. 2012;92(5):1077–87.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Ishihara R, et al. Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection. Gastrointest Endosc. 2008;67(6):799–804.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Takahashi H, et al. Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video). Gastrointest Endosc. 2010;72(2):255–64, 264 e1-2.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Alvarez Herrero L, et al. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett’s esophagus. Endoscopy. 2011;43(3):177–83.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Pouw RE, et al. Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett’s neoplasia. Gastrointest Endosc. 2011;74(1):35–43.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Guo HM, et al. Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer. World J Gastroenterol. 2014;20(18):5540–7.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Terheggen G, et al. A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrett’s neoplasia. Gut. 2017;66(5):783–93.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Bourke MJ, Neuhaus H, Bergman JJ. Endoscopic submucosal dissection: indications and application in Western endoscopy practice. Gastroenterology. 2018;154(7):1887–900.. e5PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Tamiya Y, et al. Pneumomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection. Endoscopy. 2010;42(1):8–14.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Peters FP, et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study. Am J Gastroenterol. 2006;101(7):1449–57.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Seewald S, et al. Circumferential EMR and complete removal of Barrett’s epithelium: a new approach to management of Barrett’s esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma. Gastrointest Endosc. 2003;57(7):854–9.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Ferlay J, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127(12):2893–917.PubMedCrossRefGoogle Scholar
  41. 41.
    Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1–19.CrossRefGoogle Scholar
  42. 42.
    Facciorusso A, et al. Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: a meta-analysis. World J Gastrointest Endosc. 2014;6(11):555–63.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Isomoto H, et al. Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study. Gut. 2009;58(3):331–6.PubMedCrossRefGoogle Scholar
  44. 44.
    Tanabe S, et al. Gastric cancer treated by endoscopic submucosal dissection or endoscopic mucosal resection in Japan from 2004 through 2006: JGCA nationwide registry conducted in 2013. Gastric Cancer. 2017;20(5):834–42.PubMedCrossRefGoogle Scholar
  45. 45.
    Shin KY, et al. Clinical outcomes of the endoscopic submucosal dissection of early gastric cancer are comparable between absolute and new expanded criteria. Gut Liver. 2015;9(2):181–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Yamamoto Y, et al. Current status of training for endoscopic submucosal dissection for gastric epithelial neoplasm at Cancer Institute Hospital, Japanese Foundation for Cancer Research, a famous Japanese hospital. Dig Endosc. 2012;24(Suppl 1):148–53.PubMedCrossRefGoogle Scholar
  47. 47.
    Coman RM, Gotoda T, Draganov PV. Training in endoscopic submucosal dissection. World J Gastrointest Endosc. 2013;5(8):369–78.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Gambitta P, et al. Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm. Ann Gastroenterol. 2018;31(3):338–43.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Fayez Sarkis
    • 1
  • Vijay Kanakadandi
    • 1
  • Mojtaba S. Olyaee
    • 1
  • Amit Rastogi
    • 1
    Email author
  1. 1.Department of Gastroenterology and HepatologyThe University of Kansas HospitalKansas CityUSA

Personalised recommendations