Introduction Endoscopic resection of large benign rectal lesions is becoming established as an attractive alternative to surgery. However, the optimal technique is not clear. This series compares the experience of EMR and ESD in a tertiary referral centre.
Methods A prospective review of patients undergoing endoscopic resection of neoplastic polyps in the rectosigmoid colon. Patients were tertiary referrals from experienced consultants. The polyps were considered technically challenging due to size, difficult lesion access or recurrences on previous EMR scars. Referral was made prior to surgical referral. All lesions were assessed using indigocarmine chromoendoscopy and lesions suspicious for invasive malignancy were excluded. The choice of endoscopic technique was made based on the Endoscopist's judgement of best approach for each lesion. Completeness of resection was recorded. Endoscopic follow-up was performed to assess for incomplete resection or recurrence.
Results 45 lesions were resected by ESD technique and 100 by EMR technique. For ESD procedures the median lesion size was 40 mm (range 20–150). 19/45 were salvage procedures post failed attempts at endoscopic resection. Endoscopic clearance was achieved at first attempt in 91% of the procedures. A further 7% were cleared in a subsequent procedure. One patient was referred for surgery for perforation and two patients went to surgery for unsuspected cancer found on histological examination of the resection specimen. At endoscopic follow-up 100% had complete clearance with no residual disease. There was one perforation requiring surgery, two microperforations (endoscopically managed), three delayed bleeds and two post polypectomy syndromes (conservatively managed) giving an overall complication rate of 18%. For the EMR cohort the median lesion size was 40 mm (range 20–100). All procedures were primary resections. Endoscopic clearance was achieved in 90% of cases. Two patients were referred for surgery for incomplete resection. In seven patients unsuspected cancer was found, all of whom were referred for surgery. At endoscopic follow-up 95% of cases had achieved complete clearance with no residual disease. There was seven delayed bleeds and one post polypectomy syndrome giving an overall complication rate of 8%.
Conclusion Both EMR and ESD results in an excellent complete clearance rate. While ESD appears to result in fewer recurrences at follow-up it is associated with an increased complication rate compared to EMR, predominately due to the risk of perforation. However, it is effective in patients with previous failed attempts at resection. It should be considered as an option for difficult or scarred lesions where complete clearance with EMR could be difficult.
Competing interests None declared.