Polyps are abnormal growths that can form on the inner lining of the colon. As polyps grow and become more dysplastic, they tend to invade deeper layers of the colon requiring the use of more advanced endoscopic techniques such as endoscopic submucosal dissection to ensure proper resection for optimal diagnosis and treatment.
Endoscopic submucosal dissection (ESD) can help patients with advanced precancerous polyps as well as polyps with early cancer to avoid invasive surgery while achieving excellent outcomes. Gastroenterologist Suha Jabak, MD, explains this minimally invasive procedure.
What is ESD and how does it work?
ESD is a minimally invasive endoscopic procedure that removes colon polyps with advanced histology and early cancer by dissecting through the submucosal layer of the colon, allowing for complete removal of the targeted tissue.
This procedure not only allows to remove large polyps in one piece which is important for accurate histopathological diagnosis, but also provides curative treatment for precancerous lesions as well as for specific lesions with early cancer. Dr. Jabak says.
A technically demanding procedure, ESD requires a high degree of expertise, precision and specialized training.
When is ESD appropriate?
ESD is not suitable for all colorectal polyps. It is recommended as the choice of treatment in complex polyps with risk of having early submucosal invasion. It is considered a more advanced procedure compared to endoscopic mucosal resection and a less invasive procedure than surgical resection.
"It is primarily used to remove polyps that we suspect may have early cancer that is limited to the mucosa, or to the superficial layers of the submucosa,” Dr. Jabak says. “It is not a treatment for polyps with invasive cancer, as surgery remains the only adequate resection technique.”
Diagnosis and evaluation
The decision to perform ESD begins with careful assessment of the polyp during colonoscopy.
"By examining the polyp endoscopically, we can predict whether it has early dysplasia, high-grade dysplasia, early cancer or invasive cancer" Dr. Jabak says. "This evaluation is done with careful examination with white light, NBI, magnification and dye chromoendoscopy. Using these different modalities, we look at the morphology of the polyp, the fine details of the mucosal surface pattern and the vascular architecture."
This detailed examination using advanced imaging technologies available within modern colonoscopes, combined with special dyes, allows gastroenterologists to accurately assess the risk of invasive cancer and choose the optimal resection technique.
Benefits and risks
ESD offers several advantages when offered to the right subset of patients. It is shown that it results in lower recurrence rates and higher complete resection rates when compared to endoscopic mucosal resection. It has also been associated with lower risk of complications and quicker recovery time when compared to surgical alternatives.
“ESD is considered an organ preserving procedure which sometimes may save patients from morbid surgical interventions, again when offered to the right patients” Dr. Jabak says.
While ESD offers significant benefits, it's not without risks. Complications include bleeding, perforations and strictures. Due to these risks, ESD procedures are performed in centers where expert gastroenterologists and surgeons work together to provide the best quality of care for the patients.
Recovery process
Recovery from ESD is similar to other endoscopic procedures.
"If the procedure was uncomplicated, patients can be discharged on the same day,” Dr. Jabak says. “If the procedure was prolonged and not straightforward, we admit patients overnight and monitor for any complications. Those patients can be discharged the next day if they are doing well.”
Identifying patients in your practice
Patients with family history of colorectal cancer, known hereditary cancer syndromes, and those with previously identified advanced polyps may benefit from seeing a specialist who is able to identify, stratify and treat high risk lesions.
Additionally, the Nebraska Medicine Cancer Risk and Prevention Clinic provides specialized care for higher-risk patients particularly those with significant family history of cancer and those with hereditary syndromes. “Providers from different specialties look at the patient in a comprehensive way,” Dr. Jabak says. “They provide genetic counseling and long-term follow-ups.”
Key takeaways
Colon polyps may harbor early cancer. It is important to be able to recognize these high-risk lesions and offer the optimal resection technique. When referring patients with high risk colorectal lesions, consider a consultation with our Gastrointestinal Care team to determine if ESD might be appropriate.
For more information or to refer a patient, please call 402.559.4015.