ASGE debate pits EMR against ESD in ‘quest for ideal endoscopic resection’
SAN DIEGO — Although endoscopic submucosal dissection continues to gain ground in managing colorectal laterally spreading lesions, endoscopic mucosal resection maintains a critical role, according to a debate at Digestive Diseases Week.
“The debate today perhaps should not be about EMR vs. ESD, but instead our quest for ideal endoscopic resection,” Dennis Yang, MD, director of Third Space Endoscopy at the Center for Interventional Endoscopy at AdventHealth Orlando, told attendees. “In an ideal setting, we would probably favor en bloc resection, because it provides an accurate histopathological assessment for curative intent, and invariably is associated with a lower risk of recurrence. Unfortunately, en bloc resection with EMR is limited by the size of the snare, whereas ESD potentially allows en bloc resection irrespective of size.”
Although he has taken the opposing stance, Yang noted that he “actually love[s] EMR”, due to techniques such as thermal ablation of EMR resection margins, which have been shown to reduce the risk for recurrence.
“Adjunct techniques to piecemeal EMR have really helped us manage difficult to treat lesions with the caveat that recurrence of these lesions is still very high,” Yang said. “Modifications to EMR techniques are crucial in our global effort to reduce the risk of unnecessary surgery for benign polyps, which remains a rampant problem in the United States.”
Yang argued that ESD probably should not be performed for all laterally spreading tumors, because “it’s a technically complex procedure associated with higher rates of serious adverse events.” However, the gap between EMR and ESD continues to close with the addition of multiple training pathways currently available and increasing numbers of ESD mentors and centers in the United States.
“There is an increasing need for dedicated devices/accessories, not only to flatten the learning curve and improve resection outcomes, but also to facilitate the broader update of this technique among various centers,” Yang said.
Like Yang, Michael J. Bourke, MBBS, FRACP, clinical professor of medicine at the University of Sydney in Australia, prefaced his defense of EMR with “I also love ESD, but I believe we must match therapy to pathology.”
Bourke argued that unlike ESD, EMR is safe, efficient, inexpensive, resource-light, highly effective and definitive, with a negligible recurrence rate. Moreover, it is snare-based and “technically accessible for adequately trained endoscopists.”
Bourke admitted that “the only thing EMR can’t do is cure early cancer, but this opportunity is rare in the colon and infrequent in the rectum.”
Although Bourke found ESD to be equally efficacious as EMR for large nonpedunculated colorectal polyps — the rectum being an exception — “it’s time-consuming and inefficient, resource-intensive, comparatively expensive and consumes precious finite procedure time.”
Additionally, Bourke noted that ESD is technically challenging and “largely inaccessible for most western endoscopists due to the absence of safe upper GI training cases.”
“I love ESD, but it should be reserved to lesions with submucosal invasion because piecemeal EMR is largely consequential for benign polyps,” he said.
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Bourke MJ. Sp113: Debate: ESD vs. EMR for colorectal lateral spreading lesions: Can we be reasonable about this? ESD has a role, but most colorectal lateral spreading lesions can still be removed by EMR. Presented at: Digestive Disease Week; May 21-24, 2022; San Diego (hybrid meeting).
Yang D. Sp112. Debate: ESD vs. EMR for colorectal lateral spreading lesions: The West should be moving toward ESD of all large colorectal lateral spreading lesions. Presented at: Digestive Disease Week; May 21-24, 2022; San Diego (hybrid meeting).
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