When is ESD the Right Option for Colorectal Lesions?

Endoscopic submucosal dissection (ESD) is an advanced endoscopy technique increasingly being used to remove large as well as complex lesions from the colon and rectum (as well as uses in the upper GI system).

Consult QD sat down with Emre Gorgun, MD, to discuss the advantages and risks of ESD, and learn about new research projects underway involving the technique.

Q: When is ESD appropriate for colorectal lesions?

A: ESD is an endoscopy technique that first and foremost is for large lesions (>2 cm).

It is also useful for very complex lesions (scarred, or stuck from previous intervention) that are actually small, but difficult to remove by conventional snare polypectomy. The technique becomes very handy to remove these smaller lesions that are down to the colonic lining. Deeper cuts are used to remove them from the colonic surface.

This colon-sparing approach avoids unnecessary bowel resections. Plus, most patients go home the same day.

In other words, ESD is an important tool that advanced endoscopists should probably use a lot.

Q: Are there any patients who are not good candidates for ESD?

A: Higher-risk patients who potentially have an early cancer but cannot tolerate a major operation are actually good candidates for ESD. This technique is good for benign polyps with high-grade dysplasia or large colonic neoplasia, but not locally advanced tumors.

Q: Are there any increased risks associated with the procedure?

A: ESD can be associated with higher perforation rates because it certainly is a deeper dissection into the colonic wall.

There have also been some concerns regarding increased risk of bleeding. However, I think that when you look at some of the large series comparing ESD with conventional polyp removal, the risk of bleeding is actually smaller. The reason for that is when you do a dissection into the deep tissues, you come across a big vessel almost like a surgical procedure or an intraluminal surgery. You see the single vessel and then cut it off in direct vision, rather than in a blind fashion like when you’re using conventional polyp removal techniques. When using snares, you come across the big polyp without identifying the big vessel. You can temporarily seal it off, but subsequently it may bleed.

Q: Is ESD a cost-effective treatment option?

A: Of course, ESD can be more costly compared with snare polypectomy. However, this is a little bit like comparing apples and oranges. You are achieving something with ESD, removing a lesion that you wouldn’t be able to remove with conventional techniques.

Compared with surgery, it still provides the same result in terms of removing the lesion, but it’s even better because it’s an organ-sparing approach — and at a better cost. We presented results of a study at the Central Surgical Association meeting in Chicago in August demonstrating ESD’s cost effectiveness compared with colectomy.

Q: What kind of ESD volume has Cleveland Clinic done to date?

A: ESD is a newer technique, which originated in Japan. I started performing ESD in 2011, after training there.

To date, Cleveland Clinic has performed more than 200 ESD procedures. I am dedicated to continuous education to stay current and get ideas to take this to the next level.

Early on, we started offering advanced endoscopy courses at our national society meetings, including the American Society of Colon and Rectal Surgeons and the American College of Surgeons and few surgeons expressed interest. However, over the years, interest grew exponentially.

I think one of the reasons for this (in addition to changes in healthcare regulations) is that surgeons began to question whether colon resections were good for patients when there was often no malignancy in the final pathology. They started to think, “Why did I expose this patient to a procedure that can have high morbidity and risks when there is an alternative?”

A study our team published in the Journal of the American College of Surgeons examined our 15-year experience with lesions that didn’t have a cancer diagnosis but were not amenable for colonoscopy polyp removal. It found the final rate of identified cancer was 8.2 percent. In other words, 92 percent of the time, colectomies were performed for a benign reason.

Q: What interested you enough in this technique to make the necessary commitment?

A: I saw the good that ESD could do. I wanted to have the opportunity to treat these patients who do not necessarily have cancer in their bodies but were faced with an extensive operation.

ESD in the colon is different than in the upper GI system. The colonic wall is very thin, so performing these procedures in the stomach where it’s a thick lining is much safer than in the lower colonic area. This is why there was a lack of progress or experience gained by endoscopists in the colon area because of fear of perforation and complications. But as colorectal surgeons, we’re very familiar with the anatomy in that area and are in the unique position to be able to fix something immediately, if it were to occur. If intraluminal endoscopic techniques fail, combined endoscopic-laparoscopic surgery (CELS) using laparoscopic assisted polyp removal can be achieved before oncologic colorectal resections are needed (as shown in the images).

I saw this gap and opportunity to benefit of our patients, and decided to commit my time to work on this. In addition to my training in Japan, I also received additional training last year in Australia, where similar advanced endoscopy procedures are used.

Now, I routinely see patients from all over the country who are specifically seeking out ESD, primarily for flat polyps.

Q: What new research projects do you have underway?

A: There are a lot of new, exciting projects that we are working on.

Some are refinements or modifications of the instruments used in ESD. We are also working on different types of solutions that we inject under the lesion to lift them and allow us to do the excisions. We are developing solutions that will stay longer and allow us to use the electric cautery to work better during the dissection process.

In addition, it’s exciting to take the intraluminal surgery experience we’ve had so far and combine it with some platforms intraluminally to tackle more complex lesions. Specifically, by creating some space intraluminally inside the colon, we could potentially bring in additional instruments to allow traction and countertraction. This would ultimately help with larger lesions and make these procedures quicker, faster.

Last, we’re working on getting our experience published and cost perspective comparisons — as well as the morbidity associated with more advanced procedures.