ESD Outperforms TEM for Early Rectal Tumors : Gastroenterology | June 2026

Introduction:

Early Rectal Cancer and advanced rectal adenomas are increasingly managed with organ-preserving local excision strategies. Endoscopic Submucosal Dissection and Transanal Endoscopic Microsurgery are the two principal approaches for early rectal tumors, but comparative prospective evidence evaluating both clinical outcomes and cost-effectiveness has remained limited.

Problem Statement:

Although both ESD and TEM are widely used for local excision of early rectal tumors, previous comparisons have largely been retrospective and single-center in design, with little evidence addressing long-term oncologic outcomes, procedural quality, or healthcare economic impact. Determining the optimal organ-preserving strategy is increasingly important as minimally invasive rectal cancer management expands.

Summary:

The multicenter MUCEM study compared ESD and TEM for early rectal tumors through a combined clinical and cost-effectiveness analysis, providing one of the most comprehensive evaluations of these two local excision strategies.

The study included patients with rectal adenomas, carcinoma in situ, and uT1N0 rectal cancers suitable for either ESD or TEM depending on institutional expertise.

A total of 213 ESD procedures and 117 TEM procedures were analyzed across multiple centers.

The primary endpoint was complete resection, while secondary analyses evaluated recurrence, morbidity, quality of life, survival, and healthcare costs.

At 1 year, ESD demonstrated superior cost-effectiveness compared with TEM, with a significant incremental net monetary benefit favoring ESD.

Importantly, ESD remained the preferred strategy across a broad willingness-to-pay range, supporting its economic advantage from a healthcare system perspective.

Procedural quality outcomes strongly favored ESD, particularly regarding en bloc resection rates, which reached 99% with ESD compared with 92.5% with TEM.

High-quality en bloc excision is clinically important because it improves histopathologic assessment, margin evaluation, and long-term recurrence control.

Despite superior resection quality with ESD, there were no significant differences in overall morbidity or major complication rates between the two approaches, supporting the safety of advanced endoscopic resection.

Long-term oncologic outcomes also favored ESD.

At 3 years, disease-free survival was significantly higher following ESD compared with TEM, suggesting improved local disease control and lower recurrence risk.

Overall survival and health-related quality of life remained similar between the two groups, indicating that the oncologic advantages of ESD did not come at the expense of patient well-being.

The study is highly relevant because it challenges the historical assumption that surgical local excision necessarily provides superior oncologic outcomes for early rectal tumors.

Instead, the findings support ESD as an effective minimally invasive organ-preserving strategy capable of achieving excellent oncologic control while simultaneously reducing healthcare costs.

Clinically, the results reinforce the importance of advanced therapeutic endoscopy expertise in modern colorectal cancer management.

The superior disease-free survival observed after ESD may reflect improved margin assessment and lower rates of residual microscopic disease compared with surgical excision techniques.

The findings also have major implications for healthcare resource utilization, particularly as healthcare systems increasingly prioritize high-value minimally invasive therapies.

Importantly, successful implementation of ESD requires specialized training and institutional experience, highlighting the need for referral pathways to expert therapeutic endoscopy centers.

Future research should focus on refining patient selection, standardizing pathological assessment, and evaluating longer-term oncologic outcomes beyond three years.

Overall, the MUCEM study demonstrates that ESD is more cost-effective than TEM for early rectal tumors while providing superior en bloc resection quality and improved disease-free survival, supporting ESD as a preferred organ-preserving strategy in appropriately selected patients.