Evaluation of Endoscopic Submucosal Dissection (ESD) Efficacy

Colorectal neoplasia prevalence was 35 000 for a total number of 278 000 cancers in France during 2000. Treatment of these cancers is based on local extension especially in the digestive tract (stade) and on co-morbidities of the patient. There are many advantages to treat these cancers at an early stade (involving mucosa or superficial submucosa), since they are associated with a better prognosis with a lower cost-effectivness ratio. Indeed, in 2003 mean cost of treatment of colorectal cancer during the first year following diagnosis was 24 000 €, whereas it was only 18 000 € for early stade and up to 36 000 € for the most advanced stade. Transversal (1 week) and national survey of the French society of endoscopy (SFED) during 8 years demonstrated that among 1 millions of endoscopies (3/4 being performed with anesthesia), 8000 were performed for endosocpic treatment of early digestive cancers by endoscopic mucosal resection (EMR) or more recently by endoscopic submucosal dissection (ESD). One of the problems to diffuse these endoscopic treatments is the multiple tools required to endotherapy, and the fact that this treatment is time-consuming, whereas a simple ablation of polyps (polypectomy) smaller than 1.5 cm needs only 5 to 10 minutes. For exemple, endotherapeutic tools for polypectomy (one needle and one polypectomy loop) costs 180 € and occasionally required a couple of clips when rare (1%) hemorrhage or exceptional (1p1000) perforation occurred. Conversely, endotherapy tools for ESD of early mucosal or submucosal digestive cancers larger than 1.5 cm up to 4-5 cm, costs 1500 €, including needles, submucosal injected products, hook-knife, insulinated-knife and coagulation rasper. So, the recent T2A codification gathers these two kinds of endoscopic treatment under the same code, whatever the size of the lesion, whereas costs of tools required for their treatment are notably different especially when there are performed for inpatients hospitalized less that 2 days which is only charged 480 € added of 192 € and 53€ for salary in private exercise or 914 € in public hospital, by the national and public healthcare system. Beside the expertise required for EMR and ESD of larger early cancers, this cost does not invite to increase the frequency of EMR or ESD, taking into account that this treatment is better practised by two simultaneous endoscopists, one of them manipulating the endoscope en endotherapy tools.