Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice.

Area of Science:

• Gastroenterology
• Endoscopic Surgery
• Colorectal Oncology

Background:

• Endoscopic submucosal dissection (ESD) is a minimally invasive technique for en-bloc resection of neoplastic colorectal lesions.
• Accurate lesion stratification, architecture recognition, and depth of invasion assessment are critical for selecting appropriate patients for ESD.
• Established classification systems like Paris, LST, NBI, NICE, and JNET aid endoscopists in improving lesion detection and characterization.

Purpose of the Study:

• To evaluate the efficacy and application of Endoscopic submucosal dissection (ESD) in managing neoplastic colorectal lesions.
• To compare ESD with traditional surgical resection and endoscopic mucosal resection (EMR).
• To identify factors influencing the success and challenges of ESD in clinical practice.

Main Methods:

• Review of current literature and guidelines on Endoscopic submucosal dissection (ESD) for colorectal lesions.
• Analysis of lesion characteristics, classification systems (Paris, LST, NBI, NICE, JNET), and depth of invasion.
• Comparison of ESD outcomes with surgical resection and endoscopic mucosal resection (EMR) regarding recurrence and curative rates.
• Assessment of major complication rates (bleeding, perforation) associated with ESD.

Main Results:

• ESD is recommended for specific lesions like LST-non granular (NG), Kudo-VI type, large depressed, and protruded colonic lesions with shallow submucosal invasion.
• Submucosal invasion risk increases with lesion depth, location, and size.
• ESD demonstrates lower recurrence and higher curative resection rates compared to EMR, particularly for larger lesions.
• Major complications, including bleeding (up to 11%) and perforation (up to 16%), can occur.

Conclusions:

• Endoscopic submucosal dissection (ESD) is a superior endoscopic option for managing selected neoplastic colorectal lesions, offering better outcomes than EMR.
• Accurate patient selection based on lesion characteristics and invasion depth is paramount for successful ESD.
• Challenges in widespread ESD adoption in Western countries include limited expert availability, insurance issues, and patient-specific factors.