Endoscopic submucosal dissection (ESD) provides superior en-bloc and curative resection rates for rectal neoplasia but at higher upfront cost. The cost-effectiveness of a universal rectal ESD strategy compared to EMR/ESD is unexplored within western practice. To evaluate the cost-effectiveness of universal rectal ESD compared with the current mixed EMR/ESD practice from St. Michael’s Hospital in Toronto, Ontario, Canada.

A decision-analytic model was developed using rectal outcomes from an institutional registry (n = 195; EMR = 89, ESD = 106). Inputs included weighted probabilities of adverse events, admission, and recurrence. Costs were derived from micro-costing and provincial reimbursement schedules (Ministry of Health Schedule of Benefits 2024 in CAD). The primary outcome focused on cost per recurrence avoided within a 12-month horizon. Sensitivity analyses examined admission policy, recurrence rates, and resource costs; uncertainty was explored using 5,000 Monte Carlo simulations.

Base procedural costs were $1,348 (EMR) and $7,007 (ESD). Incorporating adverse events and retreatments, the mean expected cost per patient was $2,650 for the current practice and $7,850 for universal ESD. Recurrence for ESD decreased from 10.6% to 3.1% (Δ = 0.075), yielding an ICER of $34,700 per recurrence avoided. In a one-way analysis, ESD was cost-saving when admission probability fell below 25% or when EMR recurrence exceeded 13%. Probabilistic analysis demonstrated ESD to be cost-effective in 72% of iterations at a willingness-to-pay threshold of $50,000 per recurrence avoided.

Table 1: Base-Case and Sensitivity Analysis Results Comparing Universal Rectal ESD versus Current EMR/ESD Practice

Universal rectal ESD substantially reduces recurrence and retreatment risk compared to current practice. Although associated with higher upfront procedural cost, it is cost-effective in centers with optimized anesthesia and selective admission protocols. These findings support expansion of rectal ESD capacity where procedural expertise and resources are available.