ESD for early digestive tumours: what endoscopic removal involves

Endoscopic submucosal dissection, or ESD, is a specialised technique that allows abnormal tissue to be removed from the inner lining of the digestive tract using an endoscope rather than an operation. It is used for precancerous changes and some small early cancers in the oesophagus (food pipe), stomach, colon and rectum. Because the work is done from the inside, there are no skin incisions. This article explains what ESD involves, who may be suitable, how to prepare and what recovery and follow-up usually look like.

What ESD is

ESD is carried out during an endoscopy. For the oesophagus and stomach, the endoscope is passed through the mouth, as in a gastroscopy. For the colon and rectum, a colonoscope is passed through the back passage, as in a colonoscopy. The specialist first examines the abnormal area closely to decide whether it is suitable for removal in this way.

A fine needle is then used to inject fluid underneath the lesion. This creates a cushion that lifts the abnormal tissue away from the muscle layer of the wall. Using a small instrument that works with a carefully controlled electrical current, the specialist cuts around and beneath the lesion, separating it from the deeper layers so that it can be removed whole. A dye may be sprayed onto the area to show its edges clearly, which helps ensure that the whole lesion is taken.

Which growths may be suitable

ESD may be offered for:

• dysplasia, meaning precancerous changes in the cells lining the oesophagus or stomach;
• small areas of early cancer that appear to be limited to the lining;
• large or complex polyps in the colon or rectum, including those that contain early cancer or carry a higher risk of it.

A key requirement is that the team is confident the abnormal cells have not spread beyond the area to be removed. Larger affected areas may need more than one session. Your specialist will base the recommendation on the findings of earlier endoscopies, biopsies and any scans.

Why removal in one piece matters

Removing a lesion whole, together with a small margin of normal tissue, gives the laboratory the full specimen to examine. This allows a very accurate diagnosis and makes it possible to judge how deep any abnormal cells reach, which is important for staging. Complete removal also reduces the chance of a polyp growing back. For some people, ESD may mean that a major operation can be avoided altogether.

How ESD compares with other options

The main alternative is surgery to remove the affected section of the digestive tract. For the oesophagus or stomach, this means an operation such as an oesophagectomy or gastrectomy, which usually involves a longer hospital stay, sometimes including intensive care, and a recovery period lasting months. For the bowel, it means removing the section of bowel where the lesion sits. Surgery may be the preferred route if abnormal cells have spread, because it removes a wider area.

Small early cancers and high-grade dysplasia of the oesophagus may be removed by endoscopic resection, and ESD is one of the techniques used for this. Leaving a large polyp in place is not usually recommended, because it can keep growing and may become cancerous, although in a few situations your age, general health and the features of the lesion may make monitoring a reasonable option. Your team will talk through each alternative with you.

Option	How it is done	Points to discuss
ESD	Through an endoscope, no skin incisions	Suitable only if abnormal cells are confined to the area removed
Surgical removal	Operation to remove part of the oesophagus, stomach or bowel	Removes a wider area; longer stay and recovery
Monitoring	Regular review without removal	Occasionally considered depending on age, health and the lesion

Preparing for ESD

Most hospitals arrange a pre-assessment before ESD. This is when you will receive specific instructions, so it is important to attend or take the call.

• Medicines: tell the team if you take any medicine that thins the blood, as it may need to be paused for a short time. Also mention diabetes medicines and iron tablets, which you may be asked to stop for a period beforehand. Only change medicines on their advice.
• Bowel preparation: for ESD in the colon or rectum, you will take a laxative so that the bowel is as clean as possible.
• Empty stomach: for ESD in the oesophagus or stomach, you will be asked not to eat or drink for a set time beforehand.
• An escort: if you have sedation or an anaesthetic, someone needs to collect you and stay with you afterwards.

On the day of the procedure

A cannula is placed in your hand or arm so that medicines can be given. ESD takes time, so most people have a sedative and painkiller that keep them relaxed and drowsy but still able to talk to staff. Some people have a general anaesthetic, particularly if the procedure is expected to be complex. For upper digestive tract ESD, a mouthpiece protects your teeth and keeps your mouth open.

The inside lining of the bowel has no pain-sensing nerves, so the dissection itself does not hurt. You may feel wind or cramping from the air used to open the bowel; tell the team if you are uncomfortable, as they can adjust what they are doing or give more pain relief. If a dye is used, it may temporarily colour your stool or urine blue. How long the procedure takes depends on the size and position of the lesion, and your doctor will give you an idea beforehand.

Recovery, risks and warning signs

Plan to spend a large part of the day in the endoscopy unit. Depending on the procedure, your team may arrange an overnight stay for monitoring. After sedation, avoid driving, drinking alcohol, operating machinery and signing legal documents for the following day.

After bowel ESD, wind pain is common and a little blood with your next bowel movement is expected. It may take a few days before you open your bowels, because the bowel was emptied beforehand. After ESD in the oesophagus, chest discomfort is common for a while; ask your team which pain relief is suitable.

Serious complications are uncommon, but the main risks include:

• bleeding, which can happen during the procedure or up to around two weeks later, although usually within the first few days;
• perforation, a small hole in the wall of the digestive tract, which may need a hospital stay and occasionally surgery;
• narrowing of the oesophagus or stomach outlet as the area heals, which can make swallowing painful and can be treated by stretching it during a later endoscopy;
• a reaction to the medicines used, or the procedure not being completed, in which case alternatives will be discussed.

Seek urgent medical care or contact emergency services if you develop severe abdominal or chest pain, a hard or swollen tummy, fever or shivering, vomiting, heavy bleeding or large clots, or black, tarry stools. Because complications can occasionally appear days later, some hospitals advise against travelling abroad for around two weeks after ESD. If you are travelling for treatment, plan your stay with this in mind and discuss it with your team.

Results and follow-up

The removed tissue is sent to a laboratory, where a specialist checks what type of cells it contains, how deep they extend and whether the edges are clear. Your team will contact you to discuss the findings and any follow-up you need, which may include further endoscopies. If the results show that abnormal cells extend further than expected, the team will discuss whether additional treatment, such as surgery, is advisable.

Next steps

If an endoscopy has found a precancerous area, a large polyp or a suspected early cancer, a gastroenterologist can explain whether ESD might be an option for you. Read more about our gastroenterology care, use Find my physician to be matched with a specialist, or see what is included in our cancer screening package.