ASGE Postgraduate Course at ACG: Innovative Practices for the Endoscopist of Today, Tomorrow and Beyond | October 2023-10B_Kothari

10B_Kothari_ASGE 2023 EMR colon

Pdf Summary

The document, presented by Dr. Shivangi T. Kothari, outlines the advantages and disadvantages of Endoscopic Mucosal Resection (EMR) versus Endoscopic Submucosal Dissection (ESD) for large colon polyps. It provides a comprehensive comparison of the two techniques based on various factors like efficacy, safety, cost, and complexity.<br /><br />**Assessment of Polyps:**<br />- **Polyp Characteristics:** Large polyps (≥2 cm) in the rectum or right colon carry a higher risk of malignancy.<br />- **Endoscopic Assessment:** It is crucial to determine if the polyp shows signs of cancer, its type, size, and location.<br /><br />**EMR Techniques and Tools:**<br />- **Do’s and Don’ts:** Proper assessment with white light and narrow-band imaging is vital, along with appropriate tattooing for location marking and ensuring the entire resection can be completed.<br />- **Technique:** Steps involve inspection, demarcation, injection, resection, edge ablation, specimen retrieval, possible prophylactic clipping, and surveillance.<br />- **Safety Practices:** Proper consent, preparation, and technique usage are emphasized to minimize risks.<br /><br />**Comparing EMR and ESD:**<br />- **EMR:** <br />  - Pros: Faster (40-120 min), safer (lower perforation/bleeding rates), less expensive, easier to perform.<br />  - Cons: Higher recurrence rates (0-20%) with piecemeal resection.<br />- **ESD:** <br />  - Pros: En bloc resection for higher accuracy, lower recurrence rates (1-5%).<br />  - Cons: Longer duration (60-240 min), higher risk, more costly, requires higher skillset, limited to expert centers.<br /><br />**Indications and Outcomes:**<br />- EMR is preferred for benign polyps due to demonstrated efficacy, safety, lower cost, and shorter learning curve.<br />- ESD is indicated when there is a suspected malignancy or significant submucosal fibrosis, requiring an en bloc resection.<br />- Recurrence rates for EMR are 15-20%, which can be managed endoscopically, whereas ESD has around a 2% recurrence rate.<br /><br />**Training and Professional Insight:**<br />- ESD requires significant training and a high level of expertise, often with a steep learning curve and limited mentorship.<br /><br />**Conclusion:**<br />EMR is generally favored for benign colon polyps due to its shorter procedure time, safety, effectiveness, and ease of use. ESD is reserved for cases with higher complexity or suspicion of cancer. The decision between EMR and ESD should be guided by the specific characteristics of the polyp and the skill level of the practitioner.

Keywords

Endoscopic Mucosal Resection

Endoscopic Submucosal Dissection

large colon polyps

polyp characteristics

EMR techniques

ESD techniques

procedure comparison

polyp malignancy

training and expertise

recurrence rates