Bridging the gap between evidence and practice

Bridging the gap between evidence and practice T he comprehensive review and meta-analysis by Bhat et al provides an updated performance comparison between endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the endoscopic treatment of early gastrointestinal neoplasias. 1 Their work reinforces the strengths and limitations of each approach, such as ESD's ability to achieve higher R0 resection rates compared to EMR's higher procedural efficiency.The review also reaffirms ESD's oncologic benefits with its higher en bloc and lower piecemeal resection rates.Despite these advantages, EMR remains the predominant technique in many Western centers, perhaps highlighting the disconnect between theoretical superiority and practical implementation.Originally developed in the mid to late 1990s, ESD has transformed into the standard method of endoscopic resection of larger superficial lesions in the gastrointestinal tract in Japan and other Asian countries. 2In contrast, its adoption across the United States has been much slower.Draganov et al suggest multiple elements contributing to this trend, such as its steeper learning curve, isolated technique found primarily within tertiary referral centers, decreased incidence of gastric cancers compared to Asian countries, higher level of expertise required for lesion selection, increased time and resource requirement, higher rate of adverse events, slower release of ESD equipment in the US, lack of proper reimbursement, and lack of ESD training centers. 3These reasons, among others, may disincentivize institutions from investing in ESD programs or from supporting workflow adjustments necessary for its widespread adoption and use.Thus, while ESD clearly offers appreciable advantages, EMR remains the pragmatic default in many regions and institutions for irrefutable justifications.To bridge this gap between evidence and implementation, an effort must be made to tailor reimbursements to accurately reflect procedural complexity, redefine credentialing metrics, expand accessibility and training pathways, and continue to develop tools that enhance procedural efficiency.Unfortunately, until these structural and systemic barriers are overcome, EMR's dominance will not be a rejection of evidence but rather reflect the realities of practice in contemporary Western medicine.