ESD: A gamechanger in colorectal lesions?
Though widely used in Japan, in Europe its application has been on the rise in recent years: How can colorectal ESD help in gastroenterology?
The history of ESD in Europe
There have been some profound developments in the treatment of colorectal lesions in recent years. For example, endoscopic submucosal dissection (ESD) has gained importance in gastroenterology. The first ESD in Germany was performed 19 years ago in Augsburg, and despite initial criticisms, it has become indispensable in the treatment of lesions in the colorectal area.1 The technique, which originated in Japan and is also much more widespread there, is gaining more interest within the medical community in recent years. Nevertheless, there is still a large gap in the quantity and quality of ESDs between Japan and Europe.
In 2017, a published study compared Asian and non-Asian data and showed that there was a clear difference between the regions. For example, delayed bleeding, perforation or recurrence of lesions were significantly higher outside of Asia. Furthermore, the overall surgery rate was higher in non-Asian countries, where ESD is perceived as a treatment option much less frequently.2
However, if we compare the data from the Asian region with that of the Augsburg centre, where the first ESD in Germany was performed, it becomes apparent: the data are enormously similar, and Augsburg performs significantly better than the average non-Asian region. This shows that it is quite possible to improve one's own medical quality many times over through continuous training of the method, and thus minimise the regional gap in terms of therapeutic success.
Why a differential diagnosis is essential
"Diagnosis first" was the motto of Prof. Dr. med. Messmann, President of the European Endoscopy Society, during his lecture at this year's UEG Week.1 In order to minimise the number of avoidable surgeries and, above all, to select the right therapy method, a differential diagnosis of colorectal lesions is essential. Various classification systems are available for this purpose, for example the NICE classification (Narrow-Band Imaging International Colorectal Endoscopic Classification), which is used to classify colonic polyps into three categories according to submucosal penetration depth. Although this classification is simple, it also makes it difficult to identify patients with lesions that would be ideal for ESD therapy. If, on the other hand, one follows the Japan NBI (Narrow-Band Imaging) Expert Team, i.e. the JNET classification, which additionally distinguishes between type 2A and 2B lesions, we could filter out patients who respond to ESD. Therefore, Prof. Dr. med. Messmann advises to use this classification scheme for a differential diagnosis.
In addition to the classification of colorectal neoplasms, there are various guidelines on how to proceed with lesions. The European Society of Gastrointestinal Endoscopy (ESGE), for example, provides guidelines on which types of lesions require which treatment. Again, the first step is accurate diagnosis by high-resolution endoscopy. This allows the size, morphology and location of the lesion to be determined, and in the next step its nature. In this course, any classification schemes come into play (NICE, JNET). Based on these criteria, it is then possible to identify whether an ESD is suitable for the lesion in question. This approach can also save resources and avoid unnecessary surgery.
In summary, the ESGE advises:
"...ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion...or for lesions that otherwise cannot be completely removed by snare-based techniques."3
The clinical reality of ESD in Germany
Looking at everyday clinical life in Germany with regard to ESD, it is striking: The centres performing ESDs in Germany are increasing significantly. Even though the Augsburg centre has the most experience and performs the highest number of treatments with more than 200 ESDs per year, the popularity of the therapy continues to grow, also in other European countries. The more frequently an ESD is performed, and the more practitioners are thus able to train for the procedure, the higher the percentage of curative resections in the colorectal area. However, it should not be forgotten that it takes some time until the outcomes of ESD treatments are satisfactory.
The Augsburg centre, for example, was only able to record a curative resection rate of 13.6% at the beginning of ESD therapy for early colorectal carcinomas, as the diagnosis was not precise enough at that time and thus affected patients were treated with ESD, although this option could not be curative for those selected. In the second study period, however, and after more precise diagnosis and exclusion of patients for whom ESD was not a curative treatment option, the rate of curative resection increased to 47.6%. This development clearly shows the importance of a precise diagnosis. Long-term data also suggests: ESD is a safe method of treating colorectal lesions if it could be classified as a curative treatment option in advance.4
All in all, it is clear that Europe has learned a lot from the Asian region when it comes to ESD. There are now numerous guidelines and classification systems that enable practitioners to learn the technique and continue to develop their own skills. In terms of these written procedures and curricula, the gap between the Asian and non-Asian regions has already been closed. In terms of clinical data and successful outcomes of ESD, the gap is also narrowing. Moreover, prospective studies in the European region are in progress, as more data on ESD from Europe is needed. When asked what tips there are for practitioners to learn ESD, Prof. Messmann suggests visiting one of the various centres in Europe and practising ESD on models, including animal models.
Visiting high-volume centres can also help to gain personal experience and also to train together with one's own team, as ESD is a group task. As promising as the method is, it must be noted that ESD is only suitable for patients who are still in the T1 stage, while the majority of those affected are already in more advanced stages when they are first diagnosed. In addition, the increase in the curative resection rate to just under 50% is a positive trend, but it is nowhere near the almost 100% cure rate of surgical resections for T1 stages.
In general, it is also essential for gastroenterology as a field to be open to new developments and therapeutic options, such as the use of artificial intelligence (AI) in everyday medical practice. Lastly, Dr. Messmann emphasises that precise diagnosis is the be-all and end-all in the treatment of colorectal lesions.1
Prof. Dr. Messmann shares his highlights of the UEG Week 2022 with our esanum team in Vienna
You can find more highlights fro the UEG Week in our special congress site.
- Prof. Dr. med. Messmann, H. (2022). Colorectal ESD in Europe: Are we closing the gap?. UEG Week 2022, Vienna, 11.10.2022.
- Fuccio L, Hassan C, Ponchon T, Mandolesi D, Farioli A, Cucchetti A, Frazzoni L, Bhandari P, Bellisario C, Bazzoli F, Repici A. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc. 2017 Jul;86(1):74-86.e17. doi: 10.1016/j.gie.2017.02.024. Epub 2017 Feb 28. PMID: 28254526.
- ESGE. (2022). DOI http://dx.doi.org/ 10.1055/a-1811-7025
Endoscopy 2022; 54.
- Ohata K, Kobayashi N, Sakai E, Takeuchi Y, Chino A, Takamaru H, Kodashima S, Hotta K, Harada K, Ikematsu H, Uraoka T, Murakami T, Tsuji S, Abe T, Katagiri A, Hori S, Michida T, Suzuki T, Fukuzawa M, Kiriyama S, Fukase K, Murakami Y, Ishikawa H, Saito Y. Long-Term Outcomes After Endoscopic Submucosal Dissection for Large Colorectal Epithelial Neoplasms: A Prospective, Multicenter, Cohort Trial from Japan. Gastroenterology. 2022 Jul 8:S0016-5085(22)00751-X. doi: 10.1053/j.gastro.2022.07.002. Epub ahead of print. PMID: 35810779.