Current evidence on endoscopic submucosal dissection (ESD) of lower gastrointestinal lesions shows that it is efficacious, but evidence on long-term survival when used to treat malignant lesions is limited in quantity. There are some concerns about safety with regard to the risk of perforation and bleeding. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.
Clinicians wishing to undertake ESD of lower gastrointestinal lesions should take the following actions.
Inform the clinical governance leads in their Trusts.
Ensure that patients understand the uncertainty about the procedure's safety and efficacy in relation to the risks of perforation and bleeding, and that conversion to open surgery may be necessary. Patients should be provided with clear written information. In addition, the use of NICE's information for the public is recommended.
Audit and review clinical outcomes of all patients having ESD of lower gastrointestinal lesions (see section 3.1).
ESD of lower gastrointestinal lesions is a technically challenging procedure and should only be carried out by clinicians with specific training in the technique. The Joint Advisory Group on Gastrointestinal Endoscopy intends to prepare training standards on this procedure.
Patient selection should be carried out either by a colorectal surgeon or by both a colorectal surgeon and an endoscopist who are experienced in this technique.
NICE encourages further research into ESD of lower gastrointestinal lesions. There should be clear documentation of the incidence of complications including perforation, haemorrhage and need for open surgery (with the reasons for this), rates of complete resection, and long-term outcomes including local recurrence and survival.