Comparison Rectal Endoscopic Submucosal Dissection to Endoscopic Mucosal Resection
Condition: Colonic Polyps
MeSH terms: Polyps; Colonic Polyps
Study type: Interventional

Summary: 
      The investigators have recently become proficient in a new, and we believe more effective
      technique for polyp removal. Known as Endoscopic Submucosal Dissection (ESD). ESD involves
      removing the polyp in one piece. It is preferable to remove the polyp in one piece as it
      minimises the chance of leaving residual polyp tissue behind. There have also been recent
      studies overseas that have shown this new technique to be quite effective. In this study,
      half of the patients will receive the newly developed technique of polyp removal (ESD), while
      the other half will receive conventional Endoscopic Mucosal Resection (EMR) treatment. This
      study will allow us to show which technique results in lower recurrence rates and is more
      effective.
    

Detailed description: 
      EMR is a very effective procedure for lesions smaller than 20 mm. With this size the polyp
      can be removed en bloc. En bloc resection is preferred as it minimises the likelihood of
      residual adenoma and enhances histological assessment. It is also curative in superficially
      invasive submucosal disease. It eliminates the need for surgery in these patients. With
      lesions larger than 20 mm, the lesion is removed piece meal, often in more than 5 pieces.
      Care is taken to ensure that no adenoma is left behind at the point of overlap between snare
      resections. However, for every additional snare resection, there is the possibility that a
      small amount of adenoma will be left behind at this overlap point. Overall, the literature
      suggests that there is approximately a 15% residual adenoma rate at repeat colonoscopy in 3
      months, which requires further treatment. With en bloc resection residual adenoma rate at
      repeat colonoscopy in is close to 0%. This has to be balanced against the relative
      inexperience with performing ESD, longer procedure time and higher complication rates. A
      randomized trial near completion is comparing endoscopic snare resection with transanal
      surgical resection for rectal polyps (24). Should this trial show that en bloc resection is
      superior in achieving complete resection without recurrence at similar complication rates,
      the endoscopic treatment strategy of large colorectal adenomas should be reconsidered. Since
      en bloc resection is technically more challenging, this should have consequences for
      credentialing, referral patterns and performance of removal of large colorectal polyps in
      reference centers only. Thus, before en bloc resection is promoted as superior, and training
      has to be intensified to comply with standards of safe oncologic resection of these lesions,
      the efficacy and safety have to be proven in a comparative randomized trial.
    

Intervention name(s): Endoscopic Submucosal Dissection; Endoscopic Mucosal Resection
Intervention type(s): Procedure; Procedure
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment