LAUSR

ESD or not ESD? This question has probably come up in the minds of many advanced endoscopists in the Western world, when debating on how to approach resection of large non-pedunculated colorectal polyps. The benefit of endoscopic submucosal dissection (ESD) is twofold. First, it can achieve en bloc curative resection of low-risk colorectal cancers (CRC)1 that have only invaded the superficial (less than 1000 µm) submucosal layer (sm1 cancers), and that do not show lymphovascular invasion or poor differentiation.2 Second, the recurrence rate following ESD is only 1%–2%.3 But the procedure carries a greater risk of complications, it requires extensive training and special skill, and perhaps more importantly for Western endoscopists, it takes a long time, patience and a different mindset.3 4 The defenders of colorectal endoscopic mucosal resection (EMR) argue that it is safe and efficient and that recurrence can easily be addressed by experts, with over 90% eradication rates after a maximum of two sessions.5 The solution to the controversy therefore focuses on this question: Is colorectal ESD worthwhile to benefit the few patients with low-risk CRC? The study by Fuccio et al 6 in Gut provides valuable insights to answer this question. The authors systematically reviewed all studies that examined the prevalence of cancer with sm1 invasion of colorectal lesions that were removed by ESD. They found an overall rate of sm invasion of 16%, of which 8% were limited …