Colorectal endoscopic submucosal dissection: patient selection and special considerations

Abstract

Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered.

Keywords: colorectal ESD; endoscopic resection; endoscopic submucosal dissection.

Figure 1

Different morphological subtypes of LST. Notes: (A) LST granular homogeneous; (B) LST granular mixed-nodular; (C, D) LST granular homogeneous with several areas of profound submucosal scarring/fibrosis (white arrows) from previous attempts at resection before referral; (E, F) LST nongranular pseudodepressed type. Abbreviation: LST, laterally spreading tumors.

Figure 2

Process of lesion-specific selection of resection technique at King’s College Hospital. Abbreviations: EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; LST, laterally spreading tumors; LST G, laterally spreading tumors granular; LST NG, laterally spreading tumors nongranular; NBI, narrow band imaging; pEMR, piecemeal endoscopic mucosal resection; SM, submucosal.

Figure 3

Examples of appropriate selection of resection technique. Notes: (A–D) En bloc resection of these 8 and 10 cm LST granular mixed-nodular lesions is the procedure of choice to aid accurate histopathologic assessment. However, hybrid ESD or pEMR is more appropriate for this 16 cm fully circumferential lesion in a 92-year-old patient (E, F) unlikely to tolerate a lengthy ESD. Significant nodular components (E, inset) should be resected in one piece and not sectioned. This was successfully resected as a day case procedure with minimal sedation, with no recurrence at the last follow-up. Abbreviations: ESD, endoscopic submucosal dissection; LST, laterally spreading tumors; pEMR, piecemeal endoscopic mucosal resection.