Endoscopic submucosal dissection (ESD) is an advanced therapeutic endoscopy procedure that allows for the resection (removal)  of tumors and growths of the esophagus, stomach, small intestine, colon and rectum without the need for traditional surgery.  It uses a thin and flexible instrument called an endoscope, which is inserted through the mouth or anus.  Once the growth is identified, it is carefully marked and then a special solution is injected between the thin layers of the wall of the digestive tract to create a cushion and a safe workspace.  Specialized instruments are then passed through the endoscope and are used to carefully dissect the growth for complete removal.  Small metallic clips and/or small sutures may be used to help the area heal more efficiently. The growth is then submitted to the pathology department where it is examined under the microscope to be sure that the removal is curative. 

Reasons for the Procedure

ESD can be used for the complete removal of large polyps and other benign or precancerous growths.  In some situations, it can be used to curatively remove early-stage cancers that are confined to the surface layer of the digestive tract.  Some examples of conditions that can be treated with ESD include:

• Barrett’s esophagus
• Squamous dysplasia of the esophagus
• Esophageal cancer
• Precancerous growths of the esophagus
• Precancerous growths and polyps of the stomach
• Stomach (gastric) cancer
• Precancerous polyps and growths of the small intestine
• Colon polyps
• Colorectal cancer
• Noncancerous growths in the digestive tract that cause symptoms such as difficulty swallowing, nausea and vomiting, gastrointestinal bleeding

Preparation

Before you have an endoscopic submucosal dissection, your doctor will want to know your health history and the medications you use.

You’ll be asked to provide the following information:

• The names and doses of all prescription medications, over-the-counter drugs and dietary supplements you take — especially diabetes medications and blood-thinning drugs, including aspirin
• Whether or not you have or ever had a drug allergy and, if so, the name of the drug
• All medical conditions you have, especially heart disease, lung disease, diabetes and blood-clotting disorders

You’ll receive written instructions about what to do the day before the procedure, including:

• You may not be able to eat or drink for many hours before the procedure. This is called fasting. Often, fasting begins at midnight before your procedure, but the specific start time can vary. You’ll be instructed when to begin. You may also not be able to smoke or chew gum during this time.
• Waiting to take certain medications. Your doctor may ask you to temporarily stop taking some medications, such as those that affect blood clotting or some medications for diabetes.

If you are having a lower gastrointestinal ESD including in the colon or rectum, you will be given instructions regarding cleansing with a bowel preparation.  Usually, it involves taking laxatives and drinking a solution that flushes the colon clean.  There is a specialized diet leading into and during the preparation period.  It is extremely important to follow the instructions carefully to ensure that the procedure will be able to be performed safely and effectively. 

Results

After the procedure, the physician explains the findings and preliminary results to the patient and family.  The tissue that is removed during the procedure is sent to the pathology lab where it is processed and analyzed by a pathologist.  Final pathology results may not be available for up to a week after the procedure and can be communicated to the patient and their providers via telephone or at an appointment.

After Procedure Care

Most patients will be able to go home on the day of the procedure.  Some patients may have to be admitted to the hospital for observation and treatment.  There may be restrictions on diet and medication prescribed to aid with the healing process.  Some medications such as certain blood thinners may be held after the procedure.   Your doctor will give you instructions before you go home.

Benefits

The greatest benefit of ESD is that in most instances curative treatment can be achieved without the need for surgery. When performed by experts, ESD is both safe and effective. In most situations, patients are able to return home the day of the procedure and resume normal activities much sooner than after surgery, which would be a more invasive and higher risk alternative. Most patients do not experience pain or discomfort after ESD.

Risks

• Common side effects may include: sore throat, nausea, excessive gas, bloating, abdominal cramping
• Serious complications are rare and can include infection, adverse reaction to anesthesia, bleeding, perforation (creating a hole in the digestive tract). In most instances, these problems can be treated without surgery.  In rare instances, surgery may be necessary. 

Alternatives

• Most conditions which are treated with ESD would otherwise require laparoscopic or open surgery. Chemotherapy or radiation treatment may be considered in patient’s who cannot have surgery. 
• In some instances, surveillance or monitoring may be offered in place of removal. This may involve periodic endoscopy or endoscopic ultrasonography and would only be appropriation certain situations.