medwireNews: The en bloc resection of large nonpedunculated colonic adenomas using endoscopic submucosal dissection (ESD) significantly reduces the 6-month recurrence rate compared with piecemeal endoscopic mucosal resection (EMR), suggest findings from the RESECT-COLON study.
The researchers note that the superior reduction in recurrence with ESD versus EMR eliminated the need for systematic early follow-up colonoscopy but came at the expense of an increase in adverse events (AEs).
The trial showed that among 318 patients with colonic lesions of more than 25 mm in size requiring endoscopy assessed for the primary outcome, the risk for recurrence at a median 6.5 months was 0.6% for the 161 patients randomly assigned to undergo ESD, compared with 5.1%, among the 157 patients instead receiving EMR. This gave a significant relative risk for recurrence in favor of ESD of 0.12.
“ESD consisted of en bloc resection around and underneath the lesion and EMR consisted of resection in several pieces using a polypectomy snare,” the team explains in the Annals of Internal Medicine. Recurrences were identified by mandatory biopsy or through resection and “were mostly small with benign histology,” they report.
Furthermore, no recurrences occurred in the 6 months after surgery with the ESD technique in 93.8% of patients who received complete en bloc resection. “This allowed patients to skip early follow-up colonoscopies, which are costly and stressful for the patient and lead to repeated bowel preparations, work absences, and lowered productivity,” highlight Jérémie Jacques (CHU de Limoges, France) and colleagues.
They add, however, that “[t]he potential advantage of ESD over EMR to reduce recurrence and follow-up colonoscopies must be balanced against a higher rate of adverse events.”
The incidence of procedure-related AEs among the 359 patients (ESD, n=177; EMR, n=182) in the safety analysis was higher with ESD than with EMR, at 35.6% versus 24.7%, giving a significant relative risk of 1.4. The AEs that occurred most frequently with ESD, compared with EMR, were intraprocedural perforations (5.7 vs 4.2%), postpolypectomy syndrome (11.9 vs 10.0%), and postprocedural bleeding (7.9 vs 5.5%), although the between-group differences for each were not statistically significant.
With regard to technical success, the study, conducted across six French referral centers from 2019 to 2021, showed that en bloc resection rates were higher in the ESD group than the EMR group (96.6 vs 10.4%). But the procedures had similar rates of technical failure (3.4 vs 1.6%), which was managed by rescue endoscopic treatment during the same session.
Jacques and team suggest that “it is likely that with the substantial skills required for both techniques in large adenomas (ESD perhaps more than EMR), performance of these procedures in expert centers should be recommended, in line with European guidelines.”
They stress the relevance of this given that “up to 20% of large benign colorectal lesions are still directly referred for surgery without endoscopic evaluation by an expert team.”
In terms of histologic outcomes, very low-risk or low-risk resection, according to the updated European Society of Gastrointestinal Endoscopy guidelines, was achieved in 90.4% of cases with ESD compared with only 6.0% in the EMR group.
The researchers conclude that “[p]atients and physicians should be aware of these study results not only to know when to choose endoscopic resection instead of surgery but also to choose the endoscopic resection strategy that best fits the patient according to the lesion, the acceptance of follow-up colonoscopy, and the available expertise at the center.”
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