Table 2 Endoscopic resection technique selection for various mucosal pathologies at different sites in the gastrointestinal tract.
Site | Histological sub type | Lesion features and size | Technique | Comments |
|---|---|---|---|---|
Esophagus | Squamous | ≤ 10 mm > 10 mm | Endoscopic mucosal resection/submucosal dissection Endoscopic submucosal dissection | En-bloc excision is optimal due to high risk of nodal metastases |
Esophagus | Barrett’s | Flat demarcated high-grade dysplasia, even extensive Nodular or bulky (>10–15 mm) lesions or those with possible minimal submucosal invasion | Endoscopic mucosal resection Endoscopic submucosal dissection | Risk of nodal metastases is low. Piecemeal excision is effective and efficient. En-bloc excision is preferred for more accurate histology and reduced local recurrence. |
Stomach | Demarcated mucosal neoplasia | Flat, depressed or focally superficially ulcerated lesion of any size. Not obvious deeply invasive cancer. | Endoscopic submucosal dissection | All lesions should be treated as cancer with risk of LNM due to presence of gastric mucosal lymphatics. Surgery can always be offered to a fit patient if pathology is unexpectedly advanced. |
Duodenum | Adenoma | Any size | Endoscopic mucosal resection | Invasive disease is readily detected and infrequent, even in very extensive laterally spreading lesions. En-bloc excision for lesions > 20 mm by endoscopic resection offers no clinical advantage as any degree of submucosal invasion confers a significant risk of nodal metastases and requires surgery for cure. |
Right colon | Laterally spreading adenoma or serrated adenoma | Any size or morphology without high-risk endoscopic features for deep-submucosal invasion | Endoscopic mucosal resection | Non-invasive lesions of all sizes can be cured by piecemeal resection. Structured surveillance is necessary to detect and treat recurrence. Covert invasive cancer is infrequent. |
Left colon and rectum | Laterally spreading adenoma or serrated adenoma | Any size or morphology without high-risk endoscopic features for deep-submucosal invasion Includes lesions with suspected superficial submucosal invasion (Pit pattern Vi) | Endoscopic mucosal resection Endoscopic submucosal dissection if resources are adequate | Same as for right colon. Some infrequent lesion morphologies may contain covert submucosal invasion and may benefit from en-bloc excision by endoscopic submucosal dissection to reduce the need for distal colonic surgery and protectomy and its perioperative and long-term morbidity risks. |
