Colorectal endoscopic submucosal dissection: a review on patient selection and indications

Background: The development of ‘third-space’-endoscopy has paved the way towards en-bloc resection of early gastrointestinal neoplasia. Endoscopic submucosal dissection (ESD) has improved the endoscopic management of colorectal lesions by facilitating R0-resection, improving histological assessment and preventing recurrence. Methods: The purpose of this review is to provide an evidence-based overview of indications for which ESD should be considered within colorectal endoscopy. Results: The development of ESD has partially bridged the gap between endoscopy and surgery, but depends heavily on adequate pre-resection visual evaluation, ruling out potential deep submucosal invasion. ESD should be considered for large colorectal polyps (≥20mm) and/or lesions diagnosed as harbouring high-grade dysplasia, in-situ carcinoma or superficial submucosal invasion. Not only has it found its way into our guidelines for the treatment of neuroendocrine neoplasms, ESD also seems a promising alternative for the controlled resection of large pedunculated lesions. ESD can also be applied in more challenging situations, such as in pre-treated lesions, post-surgical context and in patients with IBD, although this requires a high level of skill and expertise. Conclusions: In this review we have described the different indications for ESD and attempted to define its place within our current endoscopic armamentarium. For both non-expert and expert endoscopists, knowledge about ESD indications, patient selection and therapeutic alternatives, remains crucial in the care for patients with colorectal neoplasia.