Toward Improved Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in Our Practice

The management of superficial bowel neoplasia (SBN) has experienced a paradigm shift in the last few decades. Surgery was the treatment option for such lesions most of the time, especially for non-polypoidal lesions where the standard polypectomy techniques were not applicable. However, with the introduction of endoscopic mucosal resection (EMR) and its adoption as a potentially effective treatment for mucosal lesions up to 20 mm in the treatment plan for cases with SBN, the landscape of management dramatically changed. The introduction of endoscopic submucosal dissection (ESD) later expanded further the treatment algorithm, where lesions of ≥20 mm in diameter and with possible submucosal invasion were effectively dissected.[1]

The Egyptian practice community, in particular in gastroenterology and endoscopy, is expanding with the introduction of many junior endoscopists. However, in the structured training curricula, advanced endoscopic resection techniques are not formally taught. Hence, the practice community relies on the limited teaching and training resources for these techniques through hands-on training courses run mostly along the local and international conferences, together with live cases and watching stored video media, and in a few instances direct training under the direct guidance of the few local and renewed international experts. Consequently, the number of local experts in both EMR and ESD is few. Hence, the daily delivered service of resection for SBN across the country is limited, and the chance to deliver training for a wider audience of junior endoscopists is still low.[2]

There are many barriers to the wide-scale popularity of both EMR and ESD in our Egyptian practice, which may include the prevalence rates of pathological lesions in the spectrum of indications of both techniques, the lack of awareness and proper knowledge among physicians caring for patients with SBN,[2] financial constraints due to the relatively high cost, the lack of proper infrastructure within many endoscopy centers including the availability of working teams, sufficient number of magnification endoscopes, and probably more important is the deficiency of skilled endoscopists formally trained in both techniques.[2]

The door is open for major improvements in all aspects till finally high-quality EMR and ESD training programs are delivered. The improvements should initially focus on the teaching curricula of gastroenterology with the insertion of theoretical data about both techniques, enhance the positive attitude toward early detection of the lesions through the implementation of screening programs,[3] improve the interphysicians' communication for early referral of cases to highly equipped centers for treatment, and encourage the establishment of panel discussions in each center to discuss treatment for case by case. The skills of endoscopists also need major improvements through the application of well-organized training programs per the current guidelines.[4] [5] This training should include hands-on ex vivo as well as in vivo models and the observed practice of real cases on human subjects.[6] A rather more important focus is the improvement of the infrastructure of endoscopy units; this seems achievable through supplying a sufficient number of scopes with optical enhancements, construction of multidisciplinary teams, and securing a surgical backup team. Also, improve the skills of both the endoscopists and surgeons to manage such technique-related adverse events ([Fig. 1]). All these will eventually secure the delivery of high-quality EMR, and ESD with improved patient-oriented outcomes.

Fig. 1 Suggested improvements of endoscopic mucosal resection and endoscopic submucosal dissection in Egyptian practice. EMR; endoscopic mucosal resection, ESD; endoscopic submucosal dissection.

Publication History

Received: 13 June 2023

Accepted: 14 July 2023

Article published online:
07 August 2023

• References

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