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Beyond Piecemeal Polypectomy: EMR and ESD

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Current Common Dilemmas in Colorectal Surgery

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Abstract

Increasing utilization of colonoscopy and improvements in colon cancer screening modalities have led to increased detection of advanced adenomas and early-stage colon cancers. In the USA, many large, laterally spreading adenomatous colon polyps and early-stage colon cancers detected at the time of colonoscopy have traditionally been referred for surgical resection. However, with the advent and widespread adoption of endoscopic mucosal resection (EMR) over the past decade, endoscopic management of these lesions has increasingly provided a cost-effective and less invasive treatment. Nevertheless, EMR is challenging for lesions that demonstrate a non-lifting sign due to malignant submucosal invasion, fibrosis, or prior manipulation. EMR is also less suitable for polyps that may contain carcinoma since it often removes larger lesions in a piecemeal fashion, which results in difficulty to assess lateral and deep margins and significant rates of lesion persistence or recurrence. These EMR shortcomings have led in recent years to increased utilization of endoscopic submucosal dissection (ESD) for removal of colonic lesions (mainly in Asia, where ESD was invented in the late 1990s for resection of early gastric cancer). ESD offers high en bloc, R0 curative resection rates for lesions that contain carcinoma and/or demonstrate poor lifting due to fibrosis or prior manipulation including very large lesions. ESD also compares favorably to hybrid resection techniques such as combined endo-laparoscopic surgery (CELS) for colonic lesions and surgical resection techniques such as transanal endoscopic microsurgery (TEM) for rectal lesions. Unfortunately, adoption of ESD in the Western world has been relatively slow due to reimbursement and training barriers. We review here indications, techniques, and outcomes of EMR and ESD including comparative data between these two techniques and surgical techniques.

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Gastroenterology, Winthrop University Hospital, Mineola, NY, USA

    Patrick Vincent Saitta

  2. Department of Gastroenterology, Winthrop University Hospital, Mineola, NY, USA

    Krishna C. Gurram

  3. Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA

    Stavros N. Stavropoulos

  4. Division of Gastroenterology, Hepatology, & Nutrition, NYU Winthrop Hospital, Mineola, NY, USA

    Stavros N. Stavropoulos

Authors
  1. Patrick Vincent Saitta
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  2. Krishna C. Gurram
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  3. Stavros N. Stavropoulos
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Correspondence to Stavros N. Stavropoulos .

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Editors and Affiliations

  1. London Health Sciences Centre, University Hospital, London, Ontario, Canada

    Christopher M. Schlachta

  2. Mount Sinai School of Medicine, New York, New York, USA

    Patricia Sylla

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Saitta, P.V., Gurram, K.C., Stavropoulos, S.N. (2018). Beyond Piecemeal Polypectomy: EMR and ESD. In: Schlachta, C., Sylla, P. (eds) Current Common Dilemmas in Colorectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-70117-2_6

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  • DOI: https://doi.org/10.1007/978-3-319-70117-2_6

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