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  • Review Article
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Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps

Nature Reviews Gastroenterology & Hepatology volume 13, pages 486–496 (2016)Cite this article

Subjects

Key Points

  • Piecemeal endoscopic mucosal resection (PEMR) for complex colorectal polyps is an established technique with good outcomes compared with traditional surgery

  • Patient preparation and careful lesion assessment are essential to achieving good endoscopic resection outcomes for large, complex colorectal polyps

  • Colorectal endoscopic submucosal dissection (ESD) is more complex and has higher risks than PEMR but has the potential to provide an en bloc specimen for accurate histological assessment and reduced recurrence

  • ESD is the procedure of choice for endoscopically resectable lesions that have a high risk of containing very early submucosally invasive cancer

  • New devices and endoscopic platforms to make ESD safer, technically easier and quicker are under development

Abstract

Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2–7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.

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Figure 1: Schematic diagram and images of the colon wall.
Figure 2: Endoscopic images of a colonic lesion completely excised using the ESD technique.
Figure 3: Endoscopic images of the PEMR, underwater EMR and hybrid ESD–PEMR techniques.
Figure 4: PEMR technique followed by defect closure with endoscopic clips in a patient requiring early post-procedure recommencement of anticoagulation.
Figure 5: Standard ESD and hybrid ESD–EMR techniques.
Figure 6: TASER platform for the excision of complex rectal polyps and endoscopic images of TASER–ESD.

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Acknowledgements

We would like to thank N. Suzuki, A. Wawszczak, A. Polecina and the Multimedia Consultant, S. Preston, for their kind contribution in helping us collect and edit polyp images.

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  1. Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow, HA1 3UJ, UK

    Brian P. Saunders & Zacharias P. Tsiamoulos

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B.P.S. and Z.P.T. researched data for article, contributed to discussion of content, wrote, reviewed and edited the manuscript before submission.

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B.P.S. declares that he received loan equipment, teaching support and consultancy from Olympus, as well as loan equipment from Aquilant Medical. He is a paid speaker for Boston Scientific and is a paid consultant for Creo Medical. Z.P.T. declares that he has acted as a consultant for Creo Medical.

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Saunders, B., Tsiamoulos, Z. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 13, 486–496 (2016). https://doi.org/10.1038/nrgastro.2016.96

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