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Mindful choice of endoscopic resection for large colorectal lesions
  1. Heiko Pohl1,2,
  2. Michal Filip Kaminski3,4
  1. 1 Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA
  2. 2 Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  3. 3 Department of Gastroenterological Oncology, Maria-Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
  4. 4 Department of Gastroenterology, Hepatology and Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland
  1. Correspondence to Dr Heiko Pohl, Department of Gastroenterology, VA Medical Center, White River Junction, VT 05009, USA;{at}

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ESD or not ESD? This question has probably come up in the minds of many advanced endoscopists in the Western world, when debating on how to approach resection of large non-pedunculated colorectal polyps. The benefit of endoscopic submucosal dissection (ESD) is twofold. First, it can achieve en bloc curative resection of low-risk colorectal cancers (CRC)1 that have only invaded the superficial (less than 1000 µm) submucosal layer (sm1 cancers), and that do not show lymphovascular invasion or poor differentiation.2 Second, the recurrence rate following ESD is only 1%–2%.3 But the procedure carries a greater risk of complications, it requires extensive training and special skill, and perhaps more importantly for Western endoscopists, it takes a long time, patience and a different mindset.3 4 The defenders of colorectal endoscopic mucosal resection (EMR) argue that it is safe and efficient and that recurrence can easily be addressed by experts, with over 90% eradication rates after a maximum of two sessions.5 The solution to the controversy therefore focuses on this question: Is colorectal ESD worthwhile to benefit the few patients with low-risk CRC?

The study by Fuccio et al 6 in Gut provides valuable insights to answer this question. The authors systematically reviewed all studies that examined the prevalence of cancer with sm1 invasion of colorectal lesions that were removed by ESD. They found an overall rate of sm invasion of 16%, of which 8% were limited …

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  • Contributors HP and MFK equally contributed to the commentary.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The findings, statements and views expressed are those of the authors and do not necessarily represent those of the Commission, the Department of Veterans Affairs or the US Government.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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