Introduction of endoscopic submucosal dissection in the West

Table 6 Cost analysis-endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions

ESD vs Wide-field EMR for large sessile and lateral spreading lesions > 2 cm: Cost analysis

Selective ESD prevented 19 additional surgeries per 1000 cases at slightly lower cost compared with WF-EMR

U-ESD could prevent an additional 13 surgeries per 1000 cases compared with S-ESD but at substantially increased cost of > 21000 dollars (Australian) per surgery avoided

Expanded ESD criteria (Japanese Gastrointestinal Endoscopy Society) adding mainly granular lesions > 4 cm added little additional benefit

Authors stated U-ESD is “unjustified” given WF-EMR effectiveness for benign lesions of LR-SMIC

Subgroup analysis of only rectal lesions concluded WF-EMR including trans-anal resection was as effective as S-ESD and still less costly

Because of the higher prevalence of SMIC in the rectum, the incremental cost per surgery avoided by U-ESD decreased to $87066 and dropped to $32132 among non-granular rectal lesions. U-ESD became the least costly and most effective strategy among higher risk non-granular Paris 0-is rectal lateral spreading lesions

Study design: Selective ESD strategy was employed for lesions suspicious for SMIC-all others had WF-EMR. Pathology after ESD revealing high - risk SMIC necessitated surgery. LR-SMIC on pathology at the ESD were considered cured

After Behin. Gut 2017. U-ESD: Universal ESD; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; LR-SMIC: Low prevalence of low risk submucosal invasive cancer; WF-EMR: Wide field endoscopic mucosal resection; S-ESD: Selective endoscopic submucosal dissection; SMIC:submucosal invasive cancer.