Introduction The purpose of ESD and Hybrid ESD (circumferential excision and snaring) is to obtain en bloc specimen. Margins are checked for residual tissue and APC applied if appropriate.

Method Single endoscopist using ESD and Hybrid ESD (H-ESD) technique was retrospectively audited from April 2004 to August 2012. Service evaluation data of 38 patients with large sessile polyps who underwent ESD and Hybrid ESD was reviewed from a cohort of 224 colonoscopies referred for large polyp EMR. All procedures were intended as ESD. NICE recommendations for case selection were followed in 92% cases. Due to challenges in submucosal dissection of the large lesions, piecemeal resection was done after circumferential cutting. First follow-up endoscopy was performed at 3-6 months and the second at 12–14 months.

Results Mean age was 70 with 16 males and 22 females. Mean size of polyp in ESD group was 26 mm. Range 15–50 mm. Mean size in the H-ESD group was 49 mm. Range 20–100 mm. Complete resections were achieved in 17 (44%) out of 38 cases. Due to piecemeal resection pathologists were not able to confirm adequacy of excision in 12 cases. In 9 cases resection was reported incomplete on index procedure.

ESD performed in 13 (34%) cases. Complete resection achieved in 6. Out of 7 incomplete resections in the ESD group, 3 were reported by pathologists as lesion extending to the lateral margin hence incomplete excision. Histology did not comment on margin clearance in 3 ESD. 1 ESD was a sub mucosal lipoma on histology. This was an unintentional ESD for lipoma. Histology: ESD group: TVA with LGD 7, TVA with HGD 5.

H-ESD was performed in 25 (65.7%) cases. Complete resection achieved in 11 cases, incomplete resection in 7 and lateral margin clearance not confirmed in 7 H-ESD cases due to piecemeal resection. Histology: H-ESD group: TVA with LGD 16, TVA with HGD 6 and adenocarcinoma in 2 cases-one's lateral and deep margins were clear and the other was incomplete and referred to MDT.

In 4 ESD and 7 H-ESD cases there was minor bleeding controlled endoscopically at the time. 1 delayed post- HESD bleeding required 11 days of hospital stay and 2 units of blood transfusion. 1 retroperitoneal perforation and 1 case of serosal cut managed conservatively with clips and antibiotics. APC performed in 16 (42%) out of 38. Recurrence was identified in 6 H-ESD cases (15.7%). 5 local recurrences detected at 3 months and 1 local recurrence detected at 24 months.In 13 ESD cases no perforation or recurrence upto 14 months was noted despite 5 histologically incomplete dissections.

Conclusion ESD in bowel is challenging and has a long learning curve. These procedures should be performed by trained endoscopists in accredited units and a national registry should be maintained.