ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day One)

Pdf Summary

This ASGE APP course lecture outlines practical considerations for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), which are first-line endoscopic therapies for superficial neoplasia and select early GI cancers (esophagus, stomach, duodenum, colon, rectum). It frames key questions for advanced practice providers (APPs): selecting appropriate patients/lesions, educating and preparing patients, anticipating and co-managing complications, and planning short- and long-term follow-up.<br /><br />EMR is generally used for mucosa-limited lesions such as dysplasia, adenomatous polyps, and early esophageal/gastric/colorectal cancers, typically ≤2 cm (larger lesions may require piecemeal EMR). Technique involves submucosal injection to lift the lesion followed by snare resection (including band-EMR and cap-EMR variants). Adjuncts may include margin thermal ablation and prophylactic clip closure.<br /><br />ESD is preferred for larger (often >2 cm) or more complex lesions when en bloc resection is desired, especially with anticipated submucosal fibrosis, prior/recurrent lesions, tattoo at the base, residual carcinoma after EMR, non-polypoid IBD dysplasia, squamous esophageal neoplasia, and early gastric cancer. ESD includes detailed lesion assessment (WLE/NBI, chromoendoscopy, sometimes EUS), marking, injection (saline/epinephrine/methylene blue), circumferential incision, and submucosal dissection. ESD is more time-consuming, requires expertise, and carries higher perforation risk but achieves higher R0 resection and lower recurrence than EMR.<br /><br />Pre-procedure work emphasizes history/physical, anatomy and prior attempts, bleeding risk and antithrombotic management, anesthesia planning, and informed consent (risks/benefits/alternatives). Post-procedure responsibilities include monitoring for bleeding/perforation, discharge counseling, pathology review (margins, invasion depth, LVI, differentiation), MDT discussion for invasive/high-risk cases, and referral to surgery when submucosal invasion, poor differentiation, LVI, R1 margins, or non-endoscopically resectable lesions are present. Long-term surveillance is individualized based on histology, recurrence risk, and patient factors, with APPs central to coordination, education, medication optimization, and complication triage.

Asset Subtitle

Vivek Kaul, MD, FASGE

Keywords

endoscopic mucosal resection (EMR)

endoscopic submucosal dissection (ESD)

superficial gastrointestinal neoplasia

early GI cancer endoscopic therapy

lesion selection and staging (WLE/NBI/chromoendoscopy/EUS)

submucosal injection and snare resection

en bloc resection and R0 margins

perforation and post-procedure bleeding management

antithrombotic management and informed consent

pathology review (invasion depth, LVI, differentiation) and surveillance follow-up