What are the guidelines for Endoscopic Submucosal Dissection (ESD) of a polyp?

Guidelines for Endoscopic Submucosal Dissection (ESD) of Polyps

Endoscopic submucosal dissection (ESD) should be selectively used for specific polyps that cannot be adequately removed by conventional polypectomy or endoscopic mucosal resection (EMR), particularly when en bloc resection is necessary for histological assessment of suspected malignancy. 1

Indications for ESD

Primary Indications

• Large-sized lesions (>20 mm) where en bloc resection using conventional EMR is difficult 1
• Lesions suspected to have submucosal invasion (large depressed lesions or pseudodepressed LST-NG lesions) 1
• Mucosal lesions with fibrosis 1
• Local residual early carcinoma after previous endoscopic resection 1
• Non-polypoid colorectal dysplasia in patients with inflammatory bowel disease 1

Additional Considerations

• Recurrent adenomas at previous resection sites 2
• Large pedunculated polyps with wide stalks that cannot be safely removed by conventional snare techniques 3, 4
• Subpedunculated polyps (stalk <1 cm) that are difficult to capture with a snare 4

ESD Technique

Preparation and Equipment

• Use submucosal injection solution with contrast agent and low concentration adrenaline 1
• Sodium hyaluronate or colloidal solutions (like succinylated gelatin) are preferred as they provide longer-lasting lift than normal saline 1
• Use specialized ESD knives for cutting and dissection 5
• Cap or hood devices improve visibility and safety during the procedure 5

Procedural Steps

1. Submucosal injection: Inject the submucosa to lift the lesion
2. Circumferential incision: Perform a circumferential incision around the lesion with 3-4 mm margin of normal mucosa 1
3. Additional submucosal injection: Further inject the submucosa under the lesion
4. Submucosal dissection: Using controlled movements under direct view (facilitated with a cap), dissect through the expanded submucosal layer 1
5. Complete resection: Remove the lesion in one piece 1
6. Post-procedure inspection: Carefully inspect the resection site and document with photographs 1
7. Tattoo site: Mark according to local policy 1

Safety Considerations

Risk Factors for Complications

• The colon's narrow, tortuous lumen and thin wall increase the risk of complications compared to other removal techniques 1
• Caecal location 1
• Polyp size ≥40mm 1
• Endoscopist inexperience 1

Complication Rates

• Perforation is the main early adverse event, with ESD having higher perforation rates than EMR 1
• ESD perforation rates should be monitored as a key performance indicator 1
• Post-procedure bleeding rates should be monitored 1

Performance Standards

• EMR perforation rate should be <2% (aspirational standard <0.5%) 1
• EMR post-procedure bleeding rate should be <5% 1
• Recurrent/residual polyp at 12 months should be <10% (aspirational standard <5%) 1

Alternative Approaches

Hybrid ESD

• Involves partial submucosal dissection followed by en bloc snare resection 1
• Provides a bridge in safety, efficacy, and efficiency between conventional EMR and full ESD 1
• Useful for lesions with severe submucosal fibrosis or concern for submucosal invasion 1

Surgical Management

• Consider surgical therapy when malignancy is suspected or concerns about incomplete endoscopic resection exist 1
• Surgery offers the highest chance of oncologically complete resection for malignant lesions 1
• Surgery is the only treatment option when deep submucosal infiltration and lymph node infiltration are present 1

Post-Procedure Follow-up

• Check resection site 2-6 months after piecemeal endoscopic resection 1
• Positively identify, photograph, and assess scar with image enhancement techniques 1
• Provide patients with written information about post-procedure complications with recommended actions and an emergency contact number 1

Contraindications

• Known or suspected intestinal perforation is an absolute contraindication 6
• Clinically evident intestinal obstruction 6
• Neutropenic enterocolitis 6
• Hemodynamic instability requiring vasopressors 6
• Severe sepsis with organ failure 6

ESD requires specialized training and should be performed by experienced endoscopists in centers with appropriate expertise to minimize complications and optimize outcomes.