Jérémie Jacques, MD, a professor of gastroenterology at Limoges University Hospital, France, provided the following commentary to GI & Hepatology News on the implications for first-line treatment of superficial rectal neoplasia based on the study findings.
First-Line Management Decisions
Given that ESD achieved similar oncologic outcomes with shorter hospital stays and lower overall costs than TAMIS, the implications for first-line management are substantial. The DSETAMIS randomized trial provides the first high-level, head-to-head evidence comparing ESD and TAMIS for early rectal neoplasms—and its results are difficult to overlook. When an endoscopic procedure achieves comparable oncologic efficacy, fewer complications, significantly shorter hospitalization, and dramatically lower costs, the rationale for routinely favoring a surgical approach weakens considerably.
Two additional multicenter studies—one French and one Dutch—presented at DDW 2025 and now under publication further reinforce the DSETAMIS findings. Both demonstrated similarly favorable outcomes for ESD, including significantly lower recurrence rates compared with TAMIS. When three independent cohorts across three countries converge on the same conclusion, it becomes increasingly difficult for centers to justify surgery as the default first-line option.
In Europe, this transition is already underway. Over recent years, many centers have progressively adopted ESD as the preferred first-line strategy for large superficial rectal tumors, driven by structured training programs and expanding operator experience. The DSETAMIS results therefore do not initiate this shift—they validate and accelerate a movement already in progress. These data should now encourage North American centers to follow suit, enabling patients to benefit from a minimally invasive, organ-sparing approach with proven effectiveness and substantially reduced resource utilization.
Broader Eligibility for Minimally Invasive Endoscopic Treatment
The study also suggests that ESD may expand the population eligible for minimally invasive therapy. A key observation from DSETAMIS is that all crossover cases were from TAMIS to ESD, illustrating how anatomical constraints—such as proximity to the dentate line, high rectal location, or circumferential extension—may limit TAMIS feasibility but do not impede ESD.
This aligns with everyday clinical experience: a considerable proportion of rectal lesions fall outside the optimal surgical workspace yet remain entirely suitable for endoscopic resection.
When performed by operators with fully mastered expertise, rectal ESD has virtually no technical limitations, regardless of lesion size, circumferential involvement, or anatomical position—from the anal canal transition to the rectosigmoid junction—so long as indications for superficial neoplasia are respected. This represents a major distinction from TAMIS, whose safety and feasibility depend heavily on exposure, access, and working space.
Moreover, ESD has now clearly emerged as the technique of choice for all rectal polyps over 2 cm. One of the most critical and often underappreciated steps remains appropriate confirmation of indication. No superficial-appearing rectal lesion should be referred for surgery without dedicated evaluation by an ESD-trained endoscopist, ideally supported by high-quality photo documentation. This simple but essential safeguard helps prevent overtreatment and avoids unnecessary rectal surgery.
