Endoscopic Mucosal Resection vs Endoscopic Submucosal Dissection For Barrett’s Esophagus and Colorectal Neoplasia
2018; Elsevier BV; Volume: 17; Issue: 6 Linguagem: Inglês
10.1016/j.cgh.2018.09.030
ISSN1542-7714
AutoresDennis Yang, Mohamed O. Othman, Peter V. Draganov,
Tópico(s)Gastrointestinal Tumor Research and Treatment
ResumoEndoscopic resection has become the first-line therapy for the management of superficial neoplasia throughout the gastrointestinal tract. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established yet distinct techniques for the treatment of superficial gastrointestinal neoplasia. EMR is simpler and faster but is limited by its ability to resect large lesions en bloc. Limitations of piecemeal EMR of large lesions include a high rate of recurrence and a less-than-ideal tissue specimen for accurate histologic evaluation. ESD, on the other hand, allows en bloc resection regardless of lesion size, reducing risk for recurrence and facilitating precise histologic staging. However, ESD can take longer than EMR, is technically more complex, and traditionally has been associated with a higher rate of adverse events. Ultimately, the optimal endoscopic technique should be selected based on organ location, type of neoplastic lesion, and local expertise. The role of ESD has expanded in Eastern regions, beyond squamous cell lesions in the esophagus and gastric cancer to include superficial Barrett’s esophagus (BE) and colon neoplasia. However, there is controversy in Western regions over use of ESD for BE and colon neoplasia. We discuss the clinical outcomes of EMR and ESD for the treatment of superficial BE and colon neoplasia, focusing on practical considerations for formulating the most appropriate endoscopic resection approach for each patient. Endoscopic resection has become the first-line therapy for the management of superficial neoplasia throughout the gastrointestinal tract. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established yet distinct techniques for the treatment of superficial gastrointestinal neoplasia. EMR is simpler and faster but is limited by its ability to resect large lesions en bloc. Limitations of piecemeal EMR of large lesions include a high rate of recurrence and a less-than-ideal tissue specimen for accurate histologic evaluation. ESD, on the other hand, allows en bloc resection regardless of lesion size, reducing risk for recurrence and facilitating precise histologic staging. However, ESD can take longer than EMR, is technically more complex, and traditionally has been associated with a higher rate of adverse events. Ultimately, the optimal endoscopic technique should be selected based on organ location, type of neoplastic lesion, and local expertise. The role of ESD has expanded in Eastern regions, beyond squamous cell lesions in the esophagus and gastric cancer to include superficial Barrett’s esophagus (BE) and colon neoplasia. However, there is controversy in Western regions over use of ESD for BE and colon neoplasia. We discuss the clinical outcomes of EMR and ESD for the treatment of superficial BE and colon neoplasia, focusing on practical considerations for formulating the most appropriate endoscopic resection approach for each patient. The detection of dysplastic and early gastrointestinal (GI) cancer lesions has increased over recent years as a result of the concerted effort and adoption of endoscopic screening and surveillance programs.1Inadomi J.M. Screening for colorectal neoplasia.N Engl J Med. 2017; 376: 149-156Crossref PubMed Scopus (70) Google Scholar With advances in endoscopic techniques, the vast majority of these lesions can be managed adequately by endoscopy. Endoscopic mucosal resection (EMR) is an effective and safe technique for the removal of neoplastic lesions in both the upper and lower GI tract. The main limitation of EMR is the inability to resect large lesions en bloc, which can increase the risk of recurrence and hinder histopathologic examination.2Kandel P. Wallace M.B. Colorectal endoscopic mucosal resection (EMR).Best Pract Res Clin Gastroenterol. 2017; 31: 455-471Crossref PubMed Scopus (26) Google Scholar Endoscopic submucosal dissection (ESD) is an alternative technique that was developed in Japan specifically for the en bloc resection of GI neoplastic lesions regardless of their size. The advantages of ESD over EMR for select lesions has led to its routine application in Asia, but it has yet to be widely accepted in the West. The main obstacles precluding the adoption of ESD in the West include a steeper learning curve, a lengthier procedure, and a higher potential for adverse events.3Odagiri H. Yasunaga H. Complications following endoscopic submucosal dissection for gastric, esophageal, and colorectal cancer: a review of studies based on nationwide large-scale databases.Ann Transl Med. 2017; 5: 189Crossref PubMed Scopus (27) Google Scholar Nonetheless, evidence on ESD for the management of GI neoplasia continues to amount and has led to an intensified effort for its implementation in Western countries. Barrett’s esophagus (BE) is a precursor of esophageal adenocarcinoma (EAC) and follows a well-established progression from nondysplastic BE, through low-grade to high-grade dysplasia.4Singh S. Manickam P. Amin A.V. et al.Incidence of esophageal adenocarcinoma in Barrett's esophagus with low-grade dysplasia: a systematic review and meta-analysis.Gastrointest Endosc. 2014; 79 (quiz 983 e1, 983 e3): 897-909 e4Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar Currently, endoscopic therapy is a cost-effective, minimally invasive, first-line treatment for BE-associated neoplasia, with lower complication rates when compared with surgery. Although EMR is the most common technique for endoscopic resection in BE-associated neoplasia, the growth in the field of ESD potentially expands the reach of curative endoscopic therapy and may represent a preferred strategy in select cases.5Moss A. Bourke M.J. Hourigan L.F. et al.Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit.Am J Gastroenterol. 2010; 105: 1276-1283Crossref PubMed Scopus (163) Google Scholar In this section, we discuss clinical outcomes of EMR and ESD for the treatment of BE-associated neoplasia and focus on specific issues to be addressed when formulating the most appropriate individualized endoscopic resection approach. EMR is a relatively simple procedure for the resection of dysplastic or superficial EAC within the BE segment, providing a histopathologic specimen that can be used to guide subsequent therapy based on the grade of dysplasia and depth of invasion.5Moss A. Bourke M.J. Hourigan L.F. et al.Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit.Am J Gastroenterol. 2010; 105: 1276-1283Crossref PubMed Scopus (163) Google Scholar EMR can be curative in patients with low-risk superficial esophageal neoplasia.6Ell C. May A. Pech O. et al.Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).Gastrointest Endosc. 2007; 65: 3-10Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar Overall, the recurrence rate of dysplasia after curative EMR is estimated to be between 6% and 10%.7Small A.J. Sutherland S.E. Hightower J.S. et al.Comparative risk of recurrence of dysplasia and carcinoma after endoluminal eradication therapy of high-grade dysplasia versus intramucosal carcinoma in Barrett's esophagus.Gastrointest Endosc. 2015; 81 (e1-4): 1158-1166Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Factors associated with recurrence after curative EMR for superficial esophageal neoplasia include the following: (1) piecemeal resection, (2) when ablation is not performed, and (3) in long-segment BE.8Pech O. Behrens A. May A. et al.Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.Gut. 2008; 57: 1200-1206Crossref PubMed Scopus (576) Google Scholar These results further highlight the need for ablation therapy of any concomitant flat BE mucosa after localized EMR of the target area.9Shaheen N.J. Falk G.W. Iyer P.G. et al.ACG clinical guideline: diagnosis and management of Barrett's esophagus.Am J Gastroenterol. 2016; 111 (quiz 51): 30-50Crossref PubMed Scopus (974) Google Scholar One of the main disadvantages of EMR is that for lesions greater than 15 mm, piecemeal resection usually is necessary. This, in turn, inevitably yields a fragmented pathologic specimen, potentially compromising histopathologic evaluation for curative resection.10Martelli M.G. Duckworth L.V. Draganov P.V. Endoscopic submucosal dissection is superior to endoscopic mucosal resection for histologic evaluation of Barrett's esophagus and Barrett's-related neoplasia.Am J Gastroenterol. 2016; 111: 902-903Crossref PubMed Scopus (13) Google Scholar The aim of endoscopic therapy is to achieve cure. For lesions with SMI, surgery still can be avoided and endoscopic resection is considered curative if all of the following criteria are met: (1) resection margins are negative (R0 resection), (2) depth of invasion is less than 500 μm below the muscularis mucosae (superficial SMI), (3) absence of poorly differentiated or mucinous histology, and (4) absence of lymphovascular involvement. Conversely, an advantage of EMR over surgery is its safety profile. Bleeding and perforation are rare, whereas stricture formation is more common after wide-field piecemeal EMR.11Chennat J. Konda V.J. Ross A.S. et al.Complete Barrett's eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma--an American single-center experience.Am J Gastroenterol. 2009; 104: 2684-2692Crossref PubMed Scopus (216) Google Scholar, 12Desai M. Saligram S. Gupta N. et al.Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled-analysis.Gastrointest Endosc. 2017; 85: 482-495.e4Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Importantly, in most cases, adverse events can be successfully managed endoscopically without the need for surgery.12Desai M. Saligram S. Gupta N. et al.Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled-analysis.Gastrointest Endosc. 2017; 85: 482-495.e4Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar ESD was introduced in Japan in 1988 for the treatment of early gastric cancer.13Hirao M. Masuda K. Asanuma T. et al.Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine.Gastrointest Endosc. 1988; 34: 264-269Abstract Full Text PDF PubMed Scopus (325) Google Scholar The main advantage of ESD over EMR is that it allows en bloc resection of any lesion irrespective of size, thereby providing an ideal specimen for accurate histopathologic evaluation of both lateral and deep margins. Therefore, in its core, ESD aligns with well-established oncologic resection principles and rapidly has expanded to include the treatment of early squamous cell cancer of the esophagus and colonic neoplasia.14Fujiya M. Tanaka K. Dokoshi T. 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: 583-595Abstract Full Text Full Text PDF PubMed Scopus (222) Google Scholar, 15Fujishiro M. Yahagi N. Kakushima N. et al.Endoscopic submucosal dissection of esophageal squamous cell neoplasms.Clin Gastroenterol Hepatol. 2006; 4: 688-694Abstract Full Text Full Text PDF PubMed Scopus (311) Google Scholar Conversely, ESD as a therapy for BE-associated neoplasia has lagged, mostly because of the rather low incidence of BE in the East. Recently, however, expanding evidence from Europe and the United States has shed light on the potential role of ESD in the management of BE-associated neoplasia. We recently performed a meta-analysis of 11 studies on the efficacy and safety of ESD in a total of 524 lesions of BE-associated neoplasia.16Yang D. Zou F. Xiong S. et al.Endoscopic submucosal dissection for early Barrett’s neoplasia: a meta-analysis.Gastrointest Endosc. 2017; 87: 1383-1393Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar The mean lesion size was 27 mm, and the average procedure time was 108 minutes. The pooled en bloc resection rate was 93%, whereas those for R0 and curative resection were 74.5% and 64.9%, respectively. On logistic regression, R0 and curative resection rates were not found to be associated with study origin (Asia vs Europe/United States), length of BE segment, lesion characteristics (size or morphology based on Paris classification), procedural time, or length of follow-up evaluation. Adverse events, including bleeding (1.7%) and perforation (1.5%), were rare. Esophageal stricture formation was reported in 11.6%, with all cases managed successfully with endoscopic dilation. In aggregate, the estimated recurrence rate for BE-associated neoplasia after curative resection was 0.17% at a mean follow-up period of 22.9 months.16Yang D. Zou F. Xiong S. et al.Endoscopic submucosal dissection for early Barrett’s neoplasia: a meta-analysis.Gastrointest Endosc. 2017; 87: 1383-1393Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar The safety profile of ESD appears to be favorable, with most adverse events treated successfully with endoscopy alone.16Yang D. Zou F. Xiong S. et al.Endoscopic submucosal dissection for early Barrett’s neoplasia: a meta-analysis.Gastrointest Endosc. 2017; 87: 1383-1393Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 17Isomoto H. Yamaguchi N. Minami H. et al.Management of complications associated with endoscopic submucosal dissection/endoscopic mucosal resection for esophageal cancer.Dig Endosc. 2013; 25: 29-38Crossref PubMed Scopus (92) Google Scholar Similar to wide-field EMR, stricture formation remains 1 of the main obstacles to the widespread use of ESD and is related directly to the extent of the resection.16Yang D. Zou F. Xiong S. et al.Endoscopic submucosal dissection for early Barrett’s neoplasia: a meta-analysis.Gastrointest Endosc. 2017; 87: 1383-1393Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 18Ning B. Abdelfatah M.M. Othman M.O. Endoscopic submucosal dissection and endoscopic mucosal resection for early stage esophageal cancer.Ann Cardiothorac Surg. 2017; 6: 88-98Crossref PubMed Scopus (42) Google Scholar, 19Nagami Y. Ominami M. Shiba M. et al.Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection.Dig Endosc. 2018; 30: 198-205Crossref PubMed Scopus (31) Google Scholar Serial endoscopic dilations remain the mainstay therapy, but steroid administration via different routes may provide some additional benefit.19Nagami Y. Ominami M. Shiba M. et al.Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection.Dig Endosc. 2018; 30: 198-205Crossref PubMed Scopus (31) Google Scholar, 20Kawaguchi K. Kurumi H. Takeda Y. et al.Management of strictures after endoscopic submucosal dissection for superficial esophageal cancer.Ann Transl Med. 2017; 5: 184Crossref PubMed Scopus (14) Google Scholar There are only a few studies comparing outcomes between EMR vs ESD for BE-associated neoplasia.21Guo H.M. Zhang X.Q. Chen M. et al.Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer.World J Gastroenterol. 2014; 20: 5540-5547Crossref PubMed Scopus (122) Google Scholar A meta-analysis evaluating the effectiveness of EMR vs ESD for superficial EAC, which included 1080 patients, reported a higher en bloc resection rate with ESD (97.1%) than EMR (49.3%), irrespective of the diameter of the lesion (P < .001). Importantly, ESD achieved a higher curative rate (92.3% with ESD vs 52.7% with EMR; P < .001), and a lower incidence of local recurrence (0.3% with ESD vs 11.5% with EMR; P < .001). Not surprisingly, the procedure length was longer with ESD compared with EMR. The risk of bleeding and stricture formation was similar between the 2 groups, whereas the perforation rate was higher for ESD than EMR (odds ratio [OR], 2.2; 95% CI, 1.08–4.47; P = .03).21Guo H.M. Zhang X.Q. Chen M. et al.Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer.World J Gastroenterol. 2014; 20: 5540-5547Crossref PubMed Scopus (122) Google Scholar Another systematic review and meta-analysis of 16 studies reported that although multiband EMR was less time consuming (mean, 36.7 min) than ESD (mean, 83.3 min), the lesion sizes removed with EMR (range, 1–30 mm) also were smaller than those treated with ESD (range, 14–85 mm).22Komeda Y. Bruno M. Koch A. EMR is not inferior to ESD for early Barrett's and EGJ neoplasia: an extensive review on outcome, recurrence and complication rates.Endosc Int Open. 2014; 2: E58-E64Crossref PubMed Google Scholar The incidence of adverse events was similar between the 2 groups. A trend for higher recurrence rate after EMR (2.6%) compared with ESD (0.7%) was noted but did not quite reach statistical significance (OR, 8.55; 95% CI, 0.91–80; P = .06).22Komeda Y. Bruno M. Koch A. EMR is not inferior to ESD for early Barrett's and EGJ neoplasia: an extensive review on outcome, recurrence and complication rates.Endosc Int Open. 2014; 2: E58-E64Crossref PubMed Google Scholar In a prospective randomized controlled study comparing multiband EMR with ESD in 40 patients with BE and superficial esophageal neoplasia, the en bloc resection rate was significantly higher with ESD when compared with EMR (100% vs 15%; P < .0001).23Terheggen G. Horn E.M. Vieth M. et al.A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrett's neoplasia.Gut. 2017; 66: 783-793Crossref PubMed Scopus (152) Google Scholar The mean procedure times for EMR and ESD were 22 and 54 minutes, respectively; however, the mean maximal diameter of the resected specimen was significantly larger in the ESD group (29 vs 18 mm; P < .0001). Curative resection, including cases of EAC limited to the superficial submucosa without other advanced features, was achieved in 53% of patients undergoing ESD but only in 12% of those treated with EMR (P = .03).23Terheggen G. Horn E.M. Vieth M. et al.A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrett's neoplasia.Gut. 2017; 66: 783-793Crossref PubMed Scopus (152) Google Scholar Based on these results, recurrence of BE-associated neoplasia would have expectantly been less frequent in patients who underwent ESD; albeit, this was not evaluated specifically in this study. Finally, the investigators reported no difference in complete remission between the 2 groups at the 3-month follow-up evaluation. Bleeding and perforation rates also were similar in both groups.23Terheggen G. Horn E.M. Vieth M. et al.A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrett's neoplasia.Gut. 2017; 66: 783-793Crossref PubMed Scopus (152) Google Scholar Endoscopic resection techniques target lesions within the BE segment that are confined to the mucosa (eg, dysplasia, intramucosal cancer) or select EAC lesions limited to the superficial SMI. Endoscopic therapy is appropriate only for lesions with either no risk or an anticipated very low risk of lymph node metastasis. Table 1 summarizes the relationship between depth of invasion and the risk of lymph node metastasis for esophageal lesions.24Eleftheriadis N. Inoue H. Ikeda H. et al.Definition and staging of early esophageal, gastric and colorectal cancer.J Tumor. 2014; 2: 161-178Google Scholar, 25Westerterp M. Koppert L.B. Buskens C.J. et al.Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction.Virchows Arch. 2005; 446: 497Crossref PubMed Scopus (284) Google Scholar, 26Ancona E. Rampado S. Cassaro M. et al.Prediction of lymph node status in superficial esophageal carcinoma.Ann Surg Oncol. 2008; 15: 3278Crossref PubMed Scopus (198) Google Scholar, 27Holscher A.H. Bollschweiler E. Schroder W. et al.Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer.Ann Surg. 2011; 254: 802-807Crossref PubMed Scopus (1) Google Scholar Predictors of lymph node metastasis include poorly differentiated histology, presence of lymphovascular invasion, and deep submucosal involvement.8Pech O. Behrens A. May A. et al.Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.Gut. 2008; 57: 1200-1206Crossref PubMed Scopus (576) Google Scholar, 28Ishihara R. Oyama T. Abe S. et al.Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population.J Gastroenterol. 2017; 52: 800-808Crossref PubMed Scopus (48) Google Scholar Hence, meticulous lesion characterization is essential before selecting the most appropriate resection strategy.Table 1Depth of Invasion and the Risk of Lymph Node Metastasis for Esophageal Neoplasia24Eleftheriadis N. Inoue H. Ikeda H. et al.Definition and staging of early esophageal, gastric and colorectal cancer.J Tumor. 2014; 2: 161-178Google Scholar, 25Westerterp M. Koppert L.B. Buskens C.J. et al.Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction.Virchows Arch. 2005; 446: 497Crossref PubMed Scopus (284) Google Scholar, 26Ancona E. Rampado S. Cassaro M. et al.Prediction of lymph node status in superficial esophageal carcinoma.Ann Surg Oncol. 2008; 15: 3278Crossref PubMed Scopus (198) Google Scholar, 27Holscher A.H. Bollschweiler E. Schroder W. et al.Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer.Ann Surg. 2011; 254: 802-807Crossref PubMed Scopus (1) Google ScholarDepth of invasionRisk of lymph node metastasism10%m20%m30%–4%sm10%–13%sm219%–26%sm354%–67%NOTE. m1 involves the epithelium without breaching the lamina propria; m2 extends into the lamina propria with intact muscularis mucosa; and m3 invades the muscularis mucosa but without submucosal involvement; the sm1 lesion extends into the upper one third of the submucosa; the sm2 lesion extends into the middle one third of the submucosa; and the sm3 lesion invades the lower one third of the submucosa.m, mucosa; sm, superficial mucosa. Open table in a new tab NOTE. m1 involves the epithelium without breaching the lamina propria; m2 extends into the lamina propria with intact muscularis mucosa; and m3 invades the muscularis mucosa but without submucosal involvement; the sm1 lesion extends into the upper one third of the submucosa; the sm2 lesion extends into the middle one third of the submucosa; and the sm3 lesion invades the lower one third of the submucosa. m, mucosa; sm, superficial mucosa. Multiple factors, including patient preference, play a role when choosing the most appropriate individualized therapy. Furthermore, it is important to emphasize that the decision to pursue ESD also should depend on local expertise because ESD still is not available for BE at most institutions in the United States. Although ESD is technically feasible and safe, it has not been shown to be superior to EMR for the excision of dysplasia or superficial EAC. Therefore, at present, EMR of target lesions followed by ablation of flat BE remains the first-line therapy. The European guidelines recommend ESD for select cases, such as lesions larger than 15 mm, poorly lifting tumors, and lesions at risk for SMI.29Pimentel-Nunes P. Dinis-Ribeiro M. Ponchon T. et al.Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline.Endoscopy. 2015; 47: 829-854Crossref PubMed Scopus (791) Google Scholar We want to propose and further expand on the following variables when selecting EMR vs ESD. EMR is limited by the diameter of the cap fitted over the endoscope, usually restricting en bloc resection of lesions less than 15 to 20 mm. Larger lesions must be removed in piecemeal fashion, resulting in fragmented specimens, making histologic assessment for curative resection difficult, if not impossible. In turn, this potentially could lead to unnecessary surgery given the lack of confirmation of margin-free neoplasia. In contrast, ESD offers en bloc resection regardless of lesion size, allowing accurate assessment of the specimen’s lateral and deep margins.10Martelli M.G. Duckworth L.V. Draganov P.V. Endoscopic submucosal dissection is superior to endoscopic mucosal resection for histologic evaluation of Barrett's esophagus and Barrett's-related neoplasia.Am J Gastroenterol. 2016; 111: 902-903Crossref PubMed Scopus (13) Google Scholar Considering this superior histopathologic assessment of the ESD specimen, it comes as no surprise that 2 recent US studies showed that ESD upstaged the dysplasia diagnosis in 55% of patients.30Coman R.M. Gotoda T. Forsmark C.E. et al.Prospective evaluation of the clinical utility of endoscopic submucosal dissection (ESD) in patients with Barrett's esophagus: a Western center experience.Endosc Int Open. 2016; 4: E715-E721Crossref PubMed Google Scholar, 31Yang D. Coman R.M. Kahaleh M. et al.Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States.Gastrointest Endosc. 2017; 86: 600-607Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Hence, we support the recommendations from the European guidelines and often resort to ESD for the removal of large lesions, particularly if they are more than 15 mm in size. ESD should be considered for bulky (Paris Is, Ip) or slightly depressed lesions (Paris IIc) given the higher risk of SMI in these select cases (Figure 1).32The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon.Gastrointest Endosc. 2003; 58: S3-S43Abstract Full Text Full Text PDF PubMed Scopus (1708) Google Scholar Discrepancy frequently is encountered between the index histology obtained by biopsy and the final EMR or ESD specimen. This likely is owing to sampling error and the limited amount of tissue obtained by forceps biopsy. Importantly, the final histopathologic assessment of the resected specimen typically is upstaged when compared with the initial biopsy evaluation.30Coman R.M. Gotoda T. Forsmark C.E. et al.Prospective evaluation of the clinical utility of endoscopic submucosal dissection (ESD) in patients with Barrett's esophagus: a Western center experience.Endosc Int Open. 2016; 4: E715-E721Crossref PubMed Google Scholar, 31Yang D. Coman R.M. Kahaleh M. et al.Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States.Gastrointest Endosc. 2017; 86: 600-607Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Therefore, lesions showing intramucosal carcinoma (particularly multifocal intramucosal carcinoma) or at least intramucosal carcinoma should be considered for ESD. An incompletely resected lesion, based on an EMR specimen showing positive lateral or deep margins on histopathology, can be approached with ESD because repeat EMR often is complicated by scarring. ESD can provide a wider en bloc resection field to facilitate evaluation and confirmation of complete removal of any residual disease. This approach is particularly appealing in nonsurgical candidates. ESD is a lengthier procedure than EMR and is associated with higher periprocedural morbidity. Furthermore, when compared with EMR, which commonly is completed in the outpatient setting, many patients often are admitted after ESD for routine observation. In our current health care system aimed at maintaining care while restraining expenditure, these differences would suggest short-term incremental costs with ESD and can be viewed as a deterrent to its adoption in the West. However, it is conceivable that in the future, with the maturation of ESD and the development of structured training programs, some of these cost differences may be mitigated by reduced perioperative complications and shorter surgical times. ESD is associated with a higher R0 resection rate and lower risk of recurrence when compared with EMR. In the long term, this could prove to be cost effective because it theoretically may reduce the need for additional endoscopic interventions. A suggested management algorithm for BE-related neoplasia is summarized in Figure 2. The early identification and removal of colon polyps has been shown to reduce the risk of death from colorectal cancer.33Zauber A.G. Winawer S.J. O’Brien M.J. et al.Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.N Engl J Med. 2012; 366: 687-696Crossref PubMed Scopus (2042) Google Scholar Presently, endoscopic resection is the preferred first-line treatment of most colorectal lesions given its associated lower cost, morbidity, and mortality when compared with surgery.34Jayanna M. Burgess N.G. Sing R. et al.Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions.Clin Gastroenterol Hepatol. 2016; 14: 271-278Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 35Ahlenstiel G. Hourigan L.F. Brown G. et al.Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosa
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