Introduction
Endoscopic mucosal resection (EMR) is widely used for large nonpedunculated colonic adenomas but requires piecemeal resection and early surveillance due to recurrence risk. Endoscopic submucosal dissection (ESD) enables en bloc resection and reduces recurrence. The RESECT-COLON trial is the only available RCT comparing these 2 strategies. It demonstrated short-term superiority of ESD. We report 36-month pre-planned secondary outcomes (clinical and medico-economic outcomes).
Aims & Methods
RESECT-COLON is a multicenter randomized controlled trial comparing ESD versus EMR for ≥25 mm for apparently benign colonic lesions. Patients were randomized 1:1. Secondary endpoints at 36 months included curative resection without surgery, quality of life (EQ-5D-5L), need for surgery during follow up, and cost-effectiveness. Curative resection without surgery was defined as absence of recurrence at the end of follow-up or surgery during follow-up. Longitudinal quality of life was analyzed using mixed models. Economic evaluation was conducted from the healthcare payer perspective over 36 months.
Results
A total of 351 patients were analyzed. At 36 months, curative resection without surgery was achieved in 93.3% of patients, with no significant difference between groups (95.3% ESD vs 91.3% EMR; RR 1.04 [0.98–1.10]).
The need for surgery during follow-up was low and similar between groups (5.7% overall; 4.6% ESD vs 6.8% EMR; RR 0.69 [0.28–1.62]).
ESD significantly reduced early recurrence (0.6% vs 5.1%) and the need for repeat procedures. Notably, one patient treated by piecemeal EMR for an intramucosal carcinoma without recurrence at 6 months developed a metastatic invasive recurrence at 18 months leading to death, illustrating the potential oncological risk of incomplete initial resection. No patient with an R0 en bloc resection at initial colonoscopy experienced recurrence during the follow-up.
Quality of life remained comparable between groups over time, with no significant treatment effect on VAS or utility scores, although a gradual decline in utility was observed over follow-up.
At 36 months, total costs were significantly lower with ESD (€3,628 [IC95% 3016 ; 4388] vs €5,445 [IC95% 3815 ; 7595]; p<0.001), demonstrating economic dominance driven by reduced surveillance and retreatment.
While long-term rates of curative resection and surgery were similar, reflecting effective management of EMR recurrences, Invasive recurrence occurs once in this RCT suggesting a high individual impact of en bloc resection. ESD markedly reduces early recurrence and avoids repeated procedures. This translates into lower healthcare resource utilization without impacting quality of life.
Conclusion
At the individual level, ESD provides superior oncological control by enabling en bloc resection, reducing recurrence risk and potentially preventing invasive progression. At the population level, although it does not significantly reduce surgery rates, ESD decreases healthcare utilization and costs, supporting its role as a cost-effective strategy for large colonic adenomas.
References
Jacques J, Schaefer M, Wallenhorst T, Rösch T, Lépilliez V, Chaussade S, Rivory J, Legros R, Chevaux JB, Leblanc S, Rostain F, Barret M, Albouys J, Belle A, Labrunie A, Preux PM, Lepetit H, Dahan M, Ponchon T, Crépin S, Marais L, Magne J, Pioche M. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial. Ann Intern Med. 2024 Jan;177(1):29-38. doi: 10.7326/M23-1812.