Should We Be More Selective with Rectal ESD? Analysis of the Prospective Multicenter Spanish CR-ESD Registry

Aims To assess the potential benefits of Endoscopic Submucosal Dissection (ESD) for rectal lesions by analyzing the final histology of resected specimens within a large prospective registry

Methods Consecutive patients were enrolled in a prospective, multicenter Spanish CR-ESD registry from January 2016 to September 2024. Only rectal ESD cases were included. Based on the final histological results of the specimen, we calculated the potential Number Needed to Treat (NNT) for ESD to avoid one surgery in the registry, assuming that EMR does not cure cases with submucosal invasion, and considering a 100% complete resection rate with no complications for both ESD and EMR.

Results The Spanish ESD database included 3,073 ESD records across all locations. For this analysis, only rectal cases were selected. A total of 686 rectal neoplasms referred for ESD were recruited, all performed by members of the ESD interest group within the GSEED Endoscopic Resection Working Group. The overall en bloc resection rate was 88.1% with R0 resection achieved in 73% of cases. The conversion rate to hybrid or piecemeal EMR was 11%, while 3% of procedures were aborted due to technical difficulties. Consequently, only 64.8% of the cases initially referred for ESD were completed as such and met curative criteria. Additionally, almost 4% of lesions referred for ESD were under 20 mm and could have been resected en bloc using EMR. Out of the total cases, 102 (14.8%) exhibited submucosal invasion; of these, 38 (5.5%) had superficial invasion, while the remaining cases had deep invasion. Among those with superficial invasion, 23% presented additional risk factors for lymphatic invasion, invalidating the curative criteria. Based on the final histological results of the specimens, ESD could potentially achieve curative resection in 89.3% of cases, whereas EMR could cure 85.1% of the total cases. Thus, the potential NNT for ESD in the registry would be approximately 24 cases (95% Confidence Interval CI: 13.04–114.31). Mixed-type lesions with nodules>20 mm and non-granular laterally spreading tumors (LST) showed a notable potential benefit, with NNTs of approximately 20 (95% CI: 12.66–41.67) and 7 (95% CI: 5.38–11.63), respectively. Similarly, Kudo Vi and JNET2B patterns demonstrated NNTs of 8 (95% CI: 5.18–23.26) and 16 (95% CI: 7.58–31.25), respectively. However, the sample included more than 10% of cases corresponding to granular homogeneous LSTs, for which the NNT to avoid surgery would be approximately 91 (95% CI: 40–200) procedures in the best-case scenario [1] [2] [3].

Conclusions The overall results of this registry suggest that rectal lesions most likely to benefit from ESD should be carefully selected based on high-risk morphology, such as non-granular LSTs, mixed-type lesions with large nodules, and surface patterns like Kudo Vi and JNET2B.

Publication History

Article published online:
27 March 2025

• References

• 1 Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M. Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54 (06): 591-622 Epub 2022 May 6. PMID: 35523224
• 2 O'Sullivan T, Craciun A, Byth K, Gupta S, Gauci JL, Cronin O, Whitfield A, Abuarisha M, Williams SJ, Lee EYT, Burgess NG, Bourke MJ.. A simplified algorithm to evaluate the risk of submucosal invasive cancer in large (≥ 20 mm) nonpedunculated colonic polyps. Endoscopy 2024; 56 (08): 596-604 Epub 2024 Mar 6. PMID: 38447957
• 3 Cronin O, Sidhu M, Shahidi N, Gupta S, O'Sullivan T, Whitfield A, Wang H, Kumar P, Hourigan LF, Byth K, Burgess NG, Bourke MJ.. Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment. Gastrointest Endosc 2022; 96 (01): 118-124 Epub 2022 Feb 24. PMID: 35219724