EMR & ESD

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are advanced organ-sparing alternatives to surgery for early GI cancers and large premalignant lesions. Both rely on submucosal injection of a lifting agent (saline-epinephrine, hydroxyethyl starch, or proprietary solutions like Eleview) to separate the mucosal target from the underlying muscularis propria.

EMR uses a snare to capture and resect lifted tissue. It is fast, technically accessible, and the procedure of choice for most colorectal lesions less than 20 mm. Larger lesions are typically resected piecemeal, which limits histologic margin assessment and increases local recurrence risk compared with en-bloc resection.

ESD uses a specialized knife (insulated-tip, hook, dual, or scissors-type) to circumferentially dissect the lesion and excavate the submucosa, yielding an en-bloc specimen regardless of size. ESD is the standard of care in much of Asia for early gastric and esophageal cancer and is increasingly adopted globally for large laterally spreading colorectal tumors and Barrett's-related neoplasia. ESD is technically demanding with longer procedure times and higher rates of perforation, but offers superior R0 resection rates and lower local recurrence than piecemeal EMR.

Hybrid techniques (ESD-EMR, pre-cutting EMR) attempt to capture the en-bloc benefit of ESD with the speed of EMR.