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6 Beyond Piecemeal Polypectomy: EMR andESD
75
Fig. 6.7 ESD procedure in extensive brosis. (a) Recurrent adenoma after segmental sigmoid
resection at the site of the surgical anastomosis. A challenging lesion due to extensive brosis (seen
as white scar tissue at the right upper border of the lesion; the border of the lesion closest to the
surgical anastomosis). The lesion was not amenable to submucosal lifting and EMR due to the
extensive brosis. (b) Coagulation marks are placed using soft coagulation current to mark the
perimeter of the resection in order to achieve en bloc resection with negative lateral margins (R0
resection). (c) ESD in progress with margination of the lesion having been achieved. Very scant
submucosal layer is visible due to the extensive brosis from prior surgical resection. (d)
Completed en bloc resection. (e) The proximity of the resection to the surgical anastomosis is
evident with protruding staples apparent. Reproduced with permission from von Renteln D,
Schmidt A, Vassiliou MC, Rudolph H-C, Caca K. Endoscopic fullthickness resection and defect
closure in the colon. Gastrointestinal Endoscopy. Elsevier. 2010
76
P.V. Saitta et al.
to CELS. There were also statistically signicant differences favoring ESD over
CELS in postoperative analgesia requirements, in transfusion requirements, as well
as in the amount of time required to resume full diet and ambulation. Furthermore,
a high en bloc and curative resection rate of approximately 91% was reported in the
ESD group. However, it is important to keep in mind that CELS was reserved for
patients with evidence of deep submucosal invasion based on results of non-curative
endoscopic resection or based on initial endoscopic impression as determined by pit
pattern analysis by magnication chromoendoscopy with narrowband imaging
[107]. In this setting, CELS offers a denitive en bloc and curative resection with
concurrent lymph node dissection due to increased likelihood of lymph node
involvement in the setting of deep submucosal invasion.
A recent systematic review conrmed the utility of CELS as a technique that
represents a viable alternative to segmental colon resection with a trend toward
decreased operative times and hospital length of stay when endoscopic methods
alone do not sufce [96]. Therefore, ESD should be considered as the primary therapy in centers of expertise for resection of T1m/sm1 cancers due to high en bloc and
curative resection rates with improved postoperative recovery time, hospital length
of stay, and complication rates compared to CELS.On the other hand, CELS should
be considered when ESD expertise is not available, after failed attempt at endoscopic resection, or after successful en bloc endoscopic resection where nal histopathologic assessment reveals a positive deep margin, deep submucosal invasion
(sm2), or other high-risk ndings (e.g., poor differentiation, tumor budding, etc.).
Transanal endoscopic microsurgery (TEM) has become one of the standard
approaches for early rectal cancer (T1N0) [108]. Prior studies have demonstrated
lower rate of positive resection margins, fragmented specimens, and recurrence
rates with this technique as compared to traditional transanal excisions for early
rectal cancer [109–111]. Transanal minimally invasive surgery (TAMIS) has also
recently been introduced as a technique for removal of early rectal cancers with low
reported rates of positive margins and postoperative complications; however, very
limited data is available comparing this technique to TEM [112]. TEM and ESD
have been compared for the management of early rectal cancers. A South Korean
study demonstrated no signicant difference in en bloc and R0 resection rates
between these two techniques (ESD vs TEM, 96.7% vs 100% and 96.7 vs 97.0%,
respectively), with no statistically signicant difference in adverse event rates but a
trend for higher adverse events after TEM (ESD vs TEM, 3.3 vs 6.1%). Furthermore,
ESD resulted in signicantly shorter procedure time (84min vs 116min) and hospital length of stay (3.6 vs 6.6days). Of note, local recurrence or metastatic progression was not noted in either group during long-term follow-up [113]. A smaller
study from Brazil also demonstrated no signicant difference in en bloc resection
rates with tumor-free margins (ESD vs TEM, 81.8 vs 84.6%, p=0.040). Differences
in procedure time (ESD vs TEM, 133±99.8 vs 150±66.3min, p=0.69) and hospital stay (ESD vs TEM, 3.8±3.3 days vs 4.08±1.7, p=0.81) favored ESD but did
not reach statistical signicance in this small study [114]. In a recent meta-analysis
of studies comparing ESD to transanal surgical local excision (LE) including TEM
(notably only four such studies were identied in this 2016 meta-analysis), there
6 Beyond Piecemeal Polypectomy: EMR andESD
77
were no signicant differences in en bloc resection rate, R0 resection rate, overall
complication rate, and tumor size between ESD and LE.When adopting the xed
effect model which takes into account the study size, ESD was associated with a
lower recurrence rate than LE (OR 0.15; 95% CI 0.03–0.87; p=0.03), while with
the random effects model, the difference was not signicant (OR 0.18; 95% CI
0.02–2.04; p=0.17) [115]. A larger systematic review comparing pooled estimates
of outcomes from single technique ESD studies and TEM studies reported improved
en bloc and R0 resection rates with TEM as compared to ESD (98.7 vs 87.8%,
p<0.001 and 88.5 vs 74.6%, p<0.001). Interestingly, in contrast to other studies,
procedure time was found to be signicantly shorter in the TEM group (67 vs
96min, p=0.003). There was no signicant difference in adverse event rates (ESD
vs TEM, 8 vs 8.4%, p=0.874) [116]. We should note here, however, that the adverse
events for ESD only included delayed rectal bleeding (3.5%) and small perforations
(3.7%) which were easily managed endoscopically with minimal or no morbidity.
In contrast, most of the adverse events of TEM (occurring in 3.7%) included suture
leaks (3.2%) and stulas (0.5%). We should also note that it is unclear whether subacute adverse events such as temporary incontinence caused by the 4cm rectoscope
used in TEM were assessed. Furthermore, despite the reported improved en bloc
and R0 resection rate with TEM, adenoma recurrence rate was higher in the TEM
group (5.2 vs 2.6%, p=0.068). Another important nding that was not addressed
and may greatly limit the validity of the ndings of this meta-analysis involves the
target lesions for each technique. Perplexingly, in the pooled ESD series, 68% of the
lesions were carcinomas compared to only 11% of the lesions targeted by TEM
being carcinomas. This suggests that the lesions in the ESD series were signicantly
more challenging than those targeted by TEM.These unusual ndings raise signicant methodological concerns regarding this comparison of pooled estimates of
ESD series to those of TEM series. Therefore, the results of the much smaller metaanalysis mentioned above looking at studies comparing the two techniques directly
appear to be more reliable than the larger systemic review. It is clear that at this
point prospective randomized trials comparing ESD and TEM for rectal adenomas
and T1 N0 carcinomas are necessary.
Conclusion
Current colorectal screening programs have increased detection of early neoplastic
lesions suitable for endoscopic resection. EMR has traditionally been used for
removal of large colon polyps and has a technical success rate of approximately
95% in high-volume centers with acceptable delayed bleeding and perforation rates
[24, 25]. Currently, this remains the primary technique utilized by endoscopists to
manage these lesions in Western countries. However, en bloc resection rate with this
technique is low as polyps >2cm frequently require piecemeal resection. This subsequently interferes with histologic assessment for negative margins, which is
imperative if early-stage (T1) colonic adenocarcinoma is present. Furthermore, this
technique results in higher recurrence rates.
78
P.V. Saitta et al.
Recently, ESD has become widely utilized in Asia for removal of large colon
polyps, lesions with prior manipulation resulting in extensive submucosal brosis,
and for lesions with suspected early adenocarcinoma. Numerous studies have demonstrated high en bloc and R0 resection rates with low recurrence and acceptable
complication rates. This technique has also been shown to compare favorably to
more invasive surgical techniques such as CELS and TEM while potentially reducing hospital length of stay and healthcare costs. However, ESD has not yet been
widely accepted in Western countries due to longer procedure times, lack of reimbursement, long learning curve, and lack of access to training. In Asian countries,
ESD training typically follows a progression from gastric to rectal to proximal
colonic lesions; however, lower prevalence of gastric dysplasia and early gastric
cancer as well as lack of ESD expertise in the West prevents this training approach
necessitating more self-directed learning and reliance on animal models.
Furthermore, Western trainees are often required to progress early in their training
to colorectal ESD to gain experience, which may result in poorer outcomes and
higher complications rates as compared to the results demonstrated by our Asian
colleagues.
Reimbursement is hampered by the lack of a specic CPT code for ESD requiring the procedure to be billed as either an unlisted code or using colon EMR coding
(CPT 45390), which yields 6.04 work RVUs and $878 facility fee according to 2017
National Medicare Averages. Therefore, the substantially higher time commitment
to complete these procedures as compared to EMR is not compensated accordingly.
Furthermore, reimbursement pales in comparison to surgical alternatives such as
laparoscopic hemicolectomy (CPT code 44205) which yields 22.95 work RVUs and
$1393 facility fee. Unfortunately, reimbursement and training challenges will likely
continue to hinder the widespread adoption of ESD in the West. Nevertheless, ESD
should be considered as a minimally invasive surgical alternative in expert centers,
and standardized training programs and guidelines should be created to further
advance expertise and implementation of this technique.
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