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Review highlights importance of understanding ESD as it becomes more widely used in the West
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A review article recently published in the American Journal of Gastroenterology emphasizes the importance of understanding the indications, limitations and techniques of endoscopic submucosal dissection as the technique becomes increasingly used in the West.
“Endoscopic submucosal dissection allows for resection of early cancerous lesions of the esophagus, stomach and colon with a high chance of curative resection,” Amit Bhatt, MD, a gastroenterologist at Cleveland Clinic, told Healio Gastroenterology. “Its advantages over traditional endoscopic mucosal resection techniques have been clearly demonstrated. Interest and practice of ESD in the West is growing, and it is important to understand the indications and techniques of ESD so appropriate patients can benefit from this innovative technique.”
Amit Bhatt
Indications
According to Bhatt and colleagues, endoscopic submucosal dissection (ESD) is indicated for gastric, esophageal and colorectal lesions, but with differing criteria largely informed by Japanese guidelines.
Patients with early gastric cancer (rare in the U.S.) with low risk for lymph node metastasis are ideal candidates for endoscopic resection, with ESD indicated over endoscopic mucosal resection or surgery based on a lesion’s size, ulceration, histology, lymphovascular involvement and depth of invasion.
The esophageal lumen is at higher risk of strictures and esophageal lesions have a higher risk for lymph node metastasis. Thus, Japanese guidelines recommend absolute indication of ESD for “intramucosal cancers involving the epithelium and lamina propria occupying < 2/3 of the lumen of the esophagus,” and relative indications of ESD for “cancers involving the muscularis mucosa or < 200-µm invasion of the submucosa.” Bhatt and colleagues note the Japanese guidelines are largely based on squamous cell carcinoma, while esophageal adenocarcinoma is the predominant malignancy in the West, for which ESD “seems reasonable to consider” at early stages.
Higher rates of curative resection and lower recurrence have been demonstrated with ESD for colorectal tumors larger than 2 cm in size, and thus Japanese guidelines indicate ESD for colorectal tumors based on size and type (laterally spreading tumor granular/nongranular type, residual/recurrent tumor or rectal carcinoid tumor). Magnifying endoscopes are used for estimating depth of invasion of colorectal lesions, which are not widely available in the West; therefore nonmagnifying endoscopic classifications are currently in development.
Equipment and technique
ESD requires distal attachments for visualization and countertraction; injection solutions to lift “a safe plane for dissection between the mucosa and muscle wall;” coagulation devices to manage bleeding; and ESD knives, a wide variety of which are available, though not always widely available in the United States.
The ESD procedure entails accurately defining tumor margins using chromoendoscopy; marking mucosal borders using an ESD needle knife or with argon plasma coagulation (not required for colon polyps as borders tend to be obvious); circumferential incision (usually partial for esophageal and colorectal lesions); and submucosal dissection.
ESD-related adverse events include immediate and delayed bleeding, both of which are more common in gastric ESD, and the latter of which can be reduced by use of proton pump inhibitors or “prophylactic coagulation of vessels in the base of the ESD defect.” Additional adverse events include perforation, most of which can be endoscopically managed, and strictures, which mostly occur in esophageal ESD and can be prevented with steroids or treated with dilation.
ESD in practice
Bhatt and colleagues recommend training by observing experts performing ESD, ideally in high-volume centers like those in Japan, then training in porcine models, which are widely available in the U.S., though Western learning curves for competency are yet to be well-defined.
Selection of patients appropriate for ESD is best achieved in a multidisciplinary context including gastroenterologists, surgeons and oncologists, and flat rectal polyps are the ideal starting point for Western trainees.
“Although ESD has been successfully adopted in Japan, western diseases, biology, and environment are significantly different than Japan,” the authors concluded. “It remains to be seen what role ESD has in the western society. The greatest potential that we foresee is in the management of early [esophageal adenocarcinoma] and flat colonic polyps.” – by Adam Leitenberger
Disclosure: The researchers report no relevant financial disclosures.
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