Introduction: Endoscopic submucosal dissection (ESD) is the gold-standard treatment for superficial lesions of the digestive tract. No medico-economic study has been conducted in Europe. Material and methods: A monocentric study was conducted including all patients undergoing ESD between January 2015 and December 2017. The global cost of hospital stays was measured by microcosting, and revenue was based on the diagnosis-related group (DRG) system. The primary objective was to assess the cost/revenue balance. A medico-economic comparison with surgery was performed as a secondary outcome. Results: A total of 193 patients were prospectively included. The cost per procedure was E3463.79, subtracted from a E2726.84 revenue, with a deficit of ÀE736.96 per stay. Presence of comorbidities/complications increasing DRG value was the only predictive factor for a positive budgetary balance in a multivariate analysis (odds ratio 49.21, 95% confidence interval 11.3-214.25, p < 0.0001). In comparison with surgery, ESD was associated with shorter length of stay (11 vs 2 days; p < 0.0001) and lower morbidity (28% vs 14%; p ¼ 0.061), lower cost (E8960 vs E1770; p < 0.0001). Conclusion: The ESD cost/revenue balance is negative in 80% of cases. Given the benefits of ESD in terms of patient morbidity and financial savings compared with surgery, the implementation of a specific ESD reimbursement is warranted.

A combination of pocket, double-clip countertraction, and isolated HybridKnife as a quick and safe strategy for colonic endoscopic submucosal dissectionThe colon is considered to be one of the most technically challenging locations for endoscopic submucosal dissection (ESD) when superficial neoplastic lesions are being treated [1]. The difficulties include: the colonic loops, intestinal motility, the folded anatomy, problems caused by inconstant gravity, and constant modification of the operative fieldof-view attributable to insufflation. Good exposure of the submucosal layer is key for safe and efficient ESD; this can be particularly challenging in the colon where it is difficult to maintain a tangential position close to the muscle layer. Although individual physicians will prefer certain tips or tricks with which they are familiar, little information is available on combinations of these technical approaches. As case numbers are increasing worldwide, and as colorectal cancer screening programs are becoming more common and effective, further technical improvements are imperative. Here, we report on our treatment strategy for colonic ESD and seek to facilitate the resection of large superficial colonic lesions. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.First, we perform a careful diagnostic evaluation using a high-definition endoscope (HQ190, Olympus). We then begin ESD using a dedicated endoscope that allows retroflexion throughout the colon (Pentax Ultraflex; 580 RD, Fujinon). Each procedure commences using a DualKnife to create a mucosal incision at one side of the lesion (▶ Fig. 1 a); we then create a pocket under the lesion ( ▶ Fig. 1 b).Further development of a pocket-like tunnel facilitates a perfect view of the submucosal layer, avoiding leakage of submucosal fluid and stabilizing the endoscope beneath the lesion. After a large pocket has been created, we complete the mucosal incision around the lesion ( ▶ Fig. 1 c). The first clip, attached to a small ring of suture thread, is passed through the operative channel and fixed beneath the lesion (▶ Fig. 1 d). The suture thread is then grasped by another clip and attached to the opposite colonic wall. This double-clip technique (also termed ring-thread countertraction) allows the remnant submucosal fibers to be tensioned ( ▶ Fig. 1 e). Use of a HybridKnife type O (Erbe Medical, Tübingen, Germany), which has an isolated tip and the capacity to deliver high-pressure injections, allows rapid and safe completion of the procedure with a perfect view of the submucosal space (▶ Fig. 1 f; ▶ Video 1). We use this strategy to efficiently, rapidly, and safely treat most patients who require colonic ESD. We suggest that such a strategy could help to make the use of colonic ESD more widespread and avoid the need for surgery for large colonic superficial neoplasia. Endoscopy_UCTN_Code_TTT_1AQ_2ADCompeting interests

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