In a series of interviews, we will be previewing this year’s 15th International Colorectal Meeting in Turin, 16-18 April. We talked to Professor Adam Dziki from Medical University, Lodz, Poland, about the benefits of colorectal endoscopic submucosal dissection (CR-ESD) some of the procedures’ key technical and anatomical concerns and some of the topics will be discussing during his presentation at the meeting.
“The ability to achieve a higher en-bloc resection rate for early stage lesions in colon and rectum represents the major advantage of ESD over the other available procedures,” began professor Dzikii. “It results in lower risk of local recurrence and high-quality of pathologic specimen, enabling precise pathologic assessment. The ESD approach makes it possible to remove lesions that were not previously amenable to complete resection endoscopically and has proved to be a safe, less invasive alternative to surgery, which is the single most important value of ESD in colorectal surgery.”
He explained that colorectal ESD is a hard to master technique and has steep learning curve, requires previous endoscopic experience, as well as training under supervision before a surgeon might achieved satisfactory results in terms of efficacy and safety. However, he added that due to the inconvenient conditions for endoscopist in colon (such as thin wall, weak manoeuvrability), ESD is associated with greater technical difficulty, increase procedure time and potential high risk of perforation than EMR or standard polypectomy. Moreover, he said that ESD is contraindicated in tumours infiltrating submucosal layer deeper than SM1 (upper third of submucosa) and therefore could not be applied to treat advanced colorectal cancers.
Professor Dziki said that the most important technical and anatomical factors, which will determine future results, are appropriate lesion and patient selection, and this should be based decisively on individual experience of the operator.
He advised that a surgeon should perform their first ESDs on smaller lesions, less than 2cm located in rectum, before moving to larger ones and located elsewhere, as colorectal ESD is the most challenging technique and carries a high-risk of complications.
“During the procedure caution and constant attention is needed, not only to properly dissect, but also to spot the complications when develop and manage them as they appear,” he warned. “In post procedural period, one must still pay attention not to omit delayed complications as bleeding and perforation may still occur.”
Overall, he said that the current evidence appears to demonstrate that colorectal ESD is safe and effective based on the large and broad body of current medical literature. He added that ESD compares favourably with other minimally invasive options as Transanal endoscopic microsurgery (TEM) or endoscopic mucosal resection (EMR). A meta-analysis performed by Akintoye et al (Endoscopy 2016) - the largest and most comprehensive assessment of colorectal ESD to date - showed that colorectal ESD is safe and effective for colorectal tumours in colon and rectum and warrants consideration as first-line therapy when an expert operator is available.
Furthermore, Arezzo et al (Surgical Endoscopy 2014) compared the outcomes of TEM vs ESD in a meta-analysis that including 11 ESD and 10 TEM series on 2,077 patients. Arezzo et al concluded that ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment. However, Professor Dziki noted that authors did state that no randomised head-to-head comparison between TEM and ESD has been performed to date and ESD become more and more utilised.
Another metanalysis by Arezzo et al (United European Gastroenterol J. 2016) compared the safety and effectiveness of ESD and EMR in the treatment of flat and sessile colorectal lesions >20mm preoperatively assessed as non-invasive. They reported that ESD achieved a higher rate of en bloc and R0 resection compared to EMR (80 vs 37%), at the cost of a higher risk of complications. On the other hand, majority of the complications after ESD can be managed endoscopically.
“As far as I am aware, there are no ongoing studies with prospective manner comparing ESD with EMR. This may be explained by the confirmed ESD superiority over EMR in colon and rectum and as a result its more frequent application,” he said. “However, I would be interested to know the results of comparison of ESD with TEM, but to my knowledge there are no such plans to run such trial. There are currently two large, multi-centre studies in Europe assessing the outcomes of ESD in colon and rectum. In one of them, Centre for Treatment of Bowel Diseases in Brzeziny, where I am the Consultant, will be taking part.”
Professor Dziki emphasised that it is important that the correct treatment is offered on an individual basis to patients, and he added that patients should be matched appropriate for ESD, not only their lesions. This may require the patient attend follow up or be able to access the treatment centre on scheduled basis.
“What is more, elderly frail patients may not tolerate a lengthy procedure and the medications used for conscious sedation,” he added. “That is why it is advised to discuss the patients with anaesthesiologist and patient`s family practitioner. The decision for choosing ESD in the treatment of early cancer should be made on the same basis as for the other cancers i.e. by MDT assessing the risks and benefits.”
Professor Dziki reminded surgeons to be patient when learning the procedure and said that it takes between 50-80 procedures to achieve satisfactory results. He added that it is essential that operators are prepared - therefore they should train in a centre of excellence, participate in workshops on animal models and constantly share their experiences with more skilled colleagues. In addition, correctly qualifying and assessing the cases will influence how swiftly operators move through their learning curve and avoid unnecessary complications.
“I believe ESD is already the gold standard in the treatment algorithms of most colorectal neoplasms in Japan and East Asia. In European settings, ESD was already stated as non-inferior to TEM for treating the early rectal cancer in European Association for Endoscopic Surgery (EAES) clinical consensus statement for early rectal cancer,” explained. “The European Society of Gastrointestinal Endoscopy (ESGE) recommends the ESD as treatment of choice for most gastric superficial neoplastic lesions including early cancers with very low risk of lymph node metastasis. In colon and rectum, ESD can be considered for removal of lesions with high suspicion of limited submucosal invasion (SM1).”
He added that ESD can also be considered for rectal lesions that have previously been subjected to several attempts at endoscopic resection but are not suitable for further standard endoscopic treatment, even though fibrosis may significantly increase the risk of perforation e.g. in ulcerative colitis.
“I think ESD has already gained its significant role in treatment of large benign lesions and early cancers in gastrointestinal tract. However, I doubt if ESD will also become the treatment of choice for every benign lesion of more than 2cm located in colon and rectum in near future, especially in Europe,” he concluded. “Over the ensuing decades, procedural techniques and equipment for ESD have evolved significantly, enabling wider applications for ESD techniques and better outcomes. The manufacturers keep me informing that in following years, the major breakthrough in equipment used for ESD is still to be presented!”