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Endoscopic submucosal dissection (ESD) of large colorectal adenomas resulted in a lower recurrence rate compared with endoscopic mucosal resection (EMR), but the more technically complex ESD had a higher rate of adverse events, a randomized controlled trial showed.

In the primary analysis of 318 patients, the recurrence rate at 6 months after ESD was 0.6% compared with 5.1% after EMR (relative risk [RR] 0.12, 95% CI 0.01-0.96), reported Jérémie Jacques, MD, PhD, of CHU de Limoges in Limoges, France, and colleagues.

Adverse events occurred in 35.6% of ESD cases versus 24.5% of EMR cases (RR 1.4, 95% CI 1.0-2.0), they noted in the .

"Patients and physicians should be aware of these study results not only to know when to choose endoscopic resection instead of surgery but also to choose the endoscopic resection strategy that best fits the patient according to the lesion, the acceptance of follow-up colonoscopy, and the available expertise at the center," the authors wrote. "The potential advantage of ESD over EMR to reduce recurrence and follow-up colonoscopies must be balanced against a higher rate of adverse events."

EMR was more widely available than ESD globally and still had a relatively low recurrence rate, suggesting "broader applicability," Jacques and team pointed out. "However, EMR requires systematic early follow-up colonoscopy," and no methods exist to predict recurrence based on polyps or the EMR procedure.

"Recurrences were mostly small with benign histology. However, endoscopic treatment of recurrence is an additional challenge and requires substantial skills using various techniques and additional follow-up, and these recurrences can be invasive cancer," the authors added. "As with ESD, for which expertise is needed to reduce the rate of adverse events, expertise is needed in EMR to reproduce low recurrence rates."

Reid Ness, MD, MPH, of Vanderbilt Health in Nashville, Tennessee, told 番茄社区app that the challenge with ESD is that it "demands more time, more expertise, and greater care in the performance of the procedure."

"The benefit of endoscopic submucosal dissection is that you get a more reliable removal of the lesion," he said, so "you don't have to go back in 6 months and look because you know you got it all."

However, someone without the time and experience to do ESD regularly may end up with more adverse events, he cautioned.

Ness, who was not involved with the study, said that the key takeaway is that ESD "offers an important option for removing very large, complex lesions that would otherwise have to go to surgery," and while a higher risk of complications exists, "in the hands of experts, it's not an inordinate risk." For patients with a large, complex polyp, a referral to an expert center for ESD is a potential alternative to resection, he added.

The primary analysis of involved 318 patients with large (≥25 mm) benign colonic lesions at six French referral centers from November 2019 to February 2021. A total of 161 patients underwent ESD (mean age 69, 39.1% women), while 157 underwent EMR (mean age 71, 47.7% women).

All procedures were performed by one of 13 physicians who were experienced in both. If technical failure occurred, they could crossover to the other technique, though "this was counted as a failure, even if it led to complete resection," the authors noted.

The resection procedure took a median 14.5 minutes for EMR and 47 minutes for ESD, with anesthesia time lasting a median 66 minutes for EMR and 104 minutes for ESD.

None of the R0-resected cases after ESD resulted in recurrence, and no risk factors for recurrence were identified in the EMR group.

The ESD group had a substantially higher en bloc resection rate (96.6%) compared with the EMR group (10.4%), but the technical failure rate was not significantly different between the groups. In the ESD group, 90.4% of cases resulted in very low-risk or low-risk resection, compared with only 6% of the EMR patients (very low risk: RR 14.22, 95% CI 8.22-24.61; low risk: RR 14.96, 95% CI 8.42-26.57).

Though neither group had patients needing surgery for technical resection failure, two ESD patients required surgery for complications. More ESD patients (5.7%) than EMR patients (2.2%) had intraprocedural perforation, and delayed bleeding was more common with ESD (7.9%) than with EMR (5.5%), but these differences were not statistically significant. Post-polypectomy syndrome was significantly more frequent with ESD (11.9%) than with EMR (5.5%; RR 2.16, 95% CI 1.05-4.45).

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