At this year’s ESCP Annual Meeting in Berlin Professor Helmut Messmann will give a keynote lecture on Endoscopic Submucosal Dissection (ESD) for early stage colorectal cancers.
Professor Messmann, Head of the Department of Internal Medicine at Augsburg Medical Centre in Germany, is one of Europe’s leading experts in ESD. An early adopter of the technique, he has been practising it since 2003 and now leads the largest centre using the technique in Europe. Professor Messmann was also involved in developing the European Society for Gastrointestinal Endoscopy Guidelines for ESD – the topic of his keynote lecture in Berlin.
ESD was developed in Japan in the early 2000s initially for gastric cancer, then oesophageal cancer and colorectal cancers.
Prof Messmann treated his first patient using ESD in 2003 – almost 15 years ago. He now leads the team at the Augsburg Centre which treats approximately 200 cases a year using the technique, the highest number of patients in Europe.
Although ESD has been in use for colorectal cancers since the early 2000’s there are still very few centres in Europe where the technique is used.
The benefits of ESD for treating colorectal cancer
ESD allows surgeons to remove tumours in one single piece rather than in smaller pieces as is done using the more traditional Endoscopic Mucosal Resection technique. This significantly reduces cancer recurrence rates which are very high with EMR when treating colorectal cancers.
Professor Messmann explains:
“With this technique there is a higher probability that you can cure the patient of cancer completely and recovery times are shorter. For instance, yesterday, I treated a patient using ESD who is being discharged today. Additionally, you are much more likely to prevent the patient from requiring much bigger surgeries at a later stage, such surgeries that are likely to result in the need for a stoma, which inevitably would have a significant impact on their quality of life.”
ESD is only suitable for patients with cancers at the T1 or earlier stages. After this point, endoscopic treatment would no longer be appropriate and other surgeries or radiotherapy would be the treatment of choice.
Why have few centres in Europe adopted ESD?
Prof Messmann explains that until recently there have been very few centres in Europe using ESD. This is because it can be very expensive initially due to a longer learning curve as well as the costs of new equipment. Additionally, ESD takes three times as long to perform than a dissection using the more common EMR, snare techniques.
The problem of the higher cost of the equipment, the longer procedure times and the length of time needed to learn the procedure has been a deterrent for surgeons and endoscopists across Europe. Even in the USA there are not many endoscopists choosing to use ESD technique.
As more data is being collected on recurrence rates and patient outcomes the reimbursement is beginning to increase in Germany. This evidence means more centres will be interested in learning more about the technique.
Prof Messmann argues that, as the procedure becomes more established, costs are beginning to fall and the learning curve is becoming less steep:
“The devices needed to perform the procedure, including electrosurgical knives specially made in Japan, are getting better and better every year. This means that I am now able to perform procedures in half the time possible in the beginning. The equipment is also getting less expensive. Our results at the Augsburg Medical Centre are now almost as good as the experts in Japan.”
Prof Messmann is keen that more European endoscopists take the opportunity to learn the technique to deliver the same beneficial results that have been seen in Japan for patients in Europe.
“In my Augsburg clinic we perform 200 of these procedures every year which gives my trainee colleagues the opportunity to develop a good level of skill and experience in ESD. This generally requires working on about 30 cases.”
The importance of screening programmes
In Germany, there has been a national cancer screening programme including colonoscopies since 2002. Prof Messmann wants to see more screening programmes across Europe to catch colon cancers very early – at the polyp stage – when cancers can more easily be resected through endoscopic procedures.
“If we can detect and resect the cancer when tumours are less than 1mm in depth into the tissue of the colon, then patients have a five year survival rate of almost 100 per cent,” he said.
“Of course this treatment option is only available for early stage colorectal cancers and again this is why I would advocate for more screening programmes like the one we have in Germany so that more cases can be diagnosed and treated early.”
“If the submucosa is involved more than 1mm then the risk for lymph node metastasis increases to 20 per cent and in these cases other surgeries or radiotherapy or chemotherapy would be a more appropriate course of treatment.”
Prof Messmann’s session will be taking place on Wednesday 20 September 2017 at 14:45 and will be of interest to all surgeons with an interest in developing their knowledge of surgical endoscopy and surgical oncology treatments.
