Colorectal endoscopic submucosal dissection: I did but now I do not
01 October 2019 (online)
At an early point in my career, I ended up taking on a role of being the senior member of our interventional endoscopy group in addition to serving as the clinical leader for the entire gastroenterology practice for the health system. At the time, I had spent 2 years performing endoscopic submucosal dissection (ESD) in clinical practice (the majority being colorectal ESD) and had a growing referral base for these procedures. However, like every other interventional endoscopist, my two junior partners were both interested performing ESD, per-oral endoscopic myotomy, and other third-space endoscopy procedures. In addition, my increasing administrative responsibilities required me to dedicate more time to administrative work and decrease the amount of time I spent in the gastrointestinal endoscopy lab. It was this culmination of events that prompted me to sit down and think about what I would do moving forward. Continue to perform colorectal ESD or not? That was the question.
On first thought, there were a lot of conflicting issues that came to mind. I had spent considerable time learning ESD and improving my technique on live cases over the past 2 years. Was that a time investment that I was willing to throw away? I was only 34 years old at the time and was worried about losing a skill that I might need later on in my career, which was just starting and could last another 30 years. Was I setting myself up to be a technologically obsolete interventional endoscopist? Both of my junior partners wanted to also perform ESD. Did we really have the volume at our center to justify having three physicians perform this procedure? Could all three of us truly perform high-quality ESD if we were splitting the total cases amongst the three of us?
Beyond the concerns about my personal career and that of my two partners, I was also beginning to struggle philosophically with the role of colorectal ESD from a medical standpoint. Was I really impacting patient outcomes with performing colorectal ESD instead of other resection techniques in the West, like piecemeal endoscopic mucosal resection (EMR) and the newly developed endoscopic full-thickness resection (EFTR)? Sure, I was getting more en bloc resections endoscopically, but was I really preventing more cancers or reducing overall mortality compared to my practice before I started doing ESD? With less risk of recurrence at the resection site with ESD, maybe I was reducing the frequency of surveillance colonoscopies these patients needed. But I noticed that I really hadn’t changed my surveillance practice much because of the number of additional adenomas for which these patients were at risk.
After a long period of thought and self-reflection, I made the smartest decision of this entire process. I asked some colleagues and close friends for advice. This advice led me to a few core principles that helped me guide my personal decision to stop doing colorectal ESD. I don’t expect every interventional endoscopist asking themselves the same questions to reach the same decision that I did. But rather, I hope these principles serve as the same words of wisdom to help guide a decision as they were to me.