The need for supplementary surgery after endoscopic treatment of colorectal neoplasms: comparing endoscopic mucosal resection and endoscopic submucosal dissection

How to master endoscopic submucosal dissection in the USA

Endoscopic submucosal dissection (ESD) is an established technique for the endoscopic therapy of dysplastic and early cancerous lesions throughout the gastrointestinal tract. The procedure requires both a sophisticated knowledge for lesion characterization and high-level endoscopic skills. As a result, the learning curve is very steep and, in Japan, it takes years to gain proficiency under the traditional Master-Apprentice teaching model. At present, as a result of multiple limitations, this training model is not applicable to the USA. Nevertheless, a unique, multipronged, stepwise approach has emerged as a viable pathway to train US endoscopists in ESD. Although this approach deserves refinement, it has already led to the expansion of ESD in the USA, has contributed to the widening of the indications for ESD, and has further developed ESD techniques. Multiple challenges remain, but they can be overcome by active collaboration between Japanese and US endoscopists and professional societies. The robust interest in ESD in the USA has drawn industry attention with a few innovations already coming to fruition and many more in development.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

Optimizing Resection of Large Colorectal Polyps

OPINION STATEMENT

Polypectomy reduces the incidence and mortality of colorectal cancer (CRC). The widespread adoption of CRC screening, more rigorous colonoscopy techniques, and advancements in endoscopic imaging have led to a greater awareness of complex polyps. Whereas surgery was once considered necessary for many large sessile or laterally spreading lesions (LSLs) in the colorectum, the majority can now be removed endoscopically. Endoscopic mucosal resection (EMR) is an established technique for treatment of colorectal LSLs. When performed by experts, EMR is highly effective and safe and can be completed in an outpatient or day-stay setting. Advancements in EMR effectiveness encompass a better understanding of the factors leading to post-EMR recurrence, protocols to recognize and treat it, and interventions that prevent recurrent or residual adenoma. New techniques for treating intra-procedural bleeding and a novel classification system to identify and inform proactive management of deep mural injury enhance the safety profile of EMR. However, each of these incremental advancements necessitates a meticulous and systematic approach that only committed and properly trained endoscopists can master. While alternative interventions such as endoscopic submucosal dissection (ESD) offer potential advantages over EMR, the added procedural complexity, risks, and costs limit the relevance of ESD to a minority of lesions in the colorectum. This article reviews the expanding body of evidence supporting EMR as the first-line treatment of colorectal LSLs ≥20 mm.