Objective To compare the cost-effectiveness of endoscopic submucosal dissection (ESD) and wide-field endoscopic mucosal resection (WF-EMR) for removing large sessile and laterally spreading colorectal lesions (LSLs) >20 mm. Design An incremental cost-effectiveness analysis using a decision tree model was performed over an 18-month time horizon. The following strategies were compared: WF-EMR, universal ESD (U-ESD) and selective ESD (S-ESD) for lesions highly suspicious for containing submucosal invasive cancer (SMIC), with WF-EMR used for the remainder. Data from a large Western cohort and the literature were used to inform the model. Effectiveness was defined as the number of surgeries avoided per 1000 cases. Incremental costs per surgery avoided are presented. Sensitivity and scenario analyses were performed. Results 1723 lesions among 1765 patients were analysed. The prevalence of SMIC and low-risk-SMIC was 8.2% and 3.1%, respectively. Endoscopic lesion assessment for SMIC had a sensitivity and specificity of 34.9% and 98.4%, respectively. S-ESD was the least expensive strategy and was also more effective than WF-EMR by preventing 19 additional surgeries per 1000 cases. 43 ESD procedures would be required in an S-ESD strategy. U-ESD would prevent another 13 surgeries compared with S-ESD, at an incremental cost per surgery avoided of US$210 112. U-ESD was only cost-effective among higher risk rectal lesions. Conclusion S-ESD is the preferred treatment strategy. However, only 43 ESDs are required per 1000 LSLs. U-ESD cannot be justified beyond high-risk rectal lesions. WF-EMR remains an effective and safe treatment option for most LSLs. Trial registration number NCT02000141.

中文翻译：

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大视野内镜黏膜切除术与内镜黏膜下切除术治疗横向扩散的结直肠病变：成本效益分析

目的比较内镜黏膜下剥离术（ESD）和大视野内镜黏膜切除术（WF-EMR）去除大于20 mm的大的无蒂和横向扩散的结直肠病变（LSLs）的成本效益。设计 使用决策树模型在 18 个月的时间范围内执行增量成本效益分析。比较了以下策略：WF-EMR、通用 ESD (U-ESD) 和选择性 ESD (S-ESD) 用于高度怀疑含有黏膜下浸润性癌 (SMIC) 的病变，其余使用 WF-EMR。来自大型西方队列的数据和文献用于为模型提供信息。有效性定义为每 1000 例避免的手术次数。介绍了每次避免的手术增加的成本。进行了敏感性和情景分析。结果 分析了 1765 名患者中的 1723 个病灶。中芯国际和低风险中芯国际的患病率分别为 8.2% 和 3.1%。中芯国际内镜病变评估的敏感性和特异性分别为 34.9% 和 98.4%。S-ESD 是最便宜的策略，而且比 WF-EMR 更有效，每 1000 例可防止 19 次额外手术。S-ESD 策略需要 43 个 ESD 程序。与 S-ESD 相比，U-ESD 可避免另外 13 次手术，每次避免的手术增加成本为 210 112 美元。U-ESD 仅在风险较高的直肠病变中具有成本效益。结论 S-ESD 是首选的治疗策略。但是，每 1000 个 LSL 只需要 43 个 ESD。除了高风险直肠病变之外，U-ESD 是不合理的。WF-EMR 仍然是大多数 LSL 的有效且安全的治疗选择。