AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States

Abstract

Endoscopic submucosal dissection (ESD) is an established endoscopic resection method in Asian countries, which is increasingly practiced in Europe and by early adopters in the United States for removal of early cancers and large lesions from the luminal gastrointestinal tract. The intent of this expert review is to provide an update regarding the clinical practice of ESD with a particular focus on its use in the United States. This review is framed around the 16 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects our experience as advanced endoscopists with extensive experience in performing and teaching others to perform ESD in the United States. Best Practice Advice 1: Endoscopic submucosal dissection should be recognized as a mature endoscopic technique that enables complete removal of lesions that are too large for en bloc endoscopic mucosal resection or are at increased risk of containing cancer. Best Practice Advice 2: The safety and feasibility of endoscopic submucosal dissection for early gastric cancer is well established. The absolute indications for curative endoscopic resection include moderately and well-differentiated, nonulcerated, mucosal lesions that are ≤2 cm in size. Best Practice Advice 3: Other relative (expanded) indications for gastric endoscopic submucosal dissection include moderately and well-differentiated superficial cancers that are >2 cm, lesions ≤3 cm with ulceration or that contain early submucosal invasion, and poorly differentiated superficial cancers ≤2 cm in size. The risk of lymph node metastasis when endoscopic submucosal dissection is performed for these indications is higher than when it is performed for absolute indications but remains acceptably low. Best Practice Advice 4: Endoscopic submucosal dissection may be considered in selected patients with Barrett's esophagus with the following features: large or bulky area of nodularity, lesions with a high likelihood of superficial submucosal invasion, recurrent dysplasia, endoscopic mucosal resection specimen showing invasive carcinoma with positive margins, equivocal preprocedural histology, and intramucosal carcinoma. Best Practice Advice 5: Endoscopic submucosal dissection is the primary modality for treatment of squamous cell dysplasia and cancer confined to the superficial esophageal mucosa. Any degree of submucosal invasion caries an increased risk of lymph node metastasis and alternative/additional therapy should be considered. Best Practice Advice 6: Duodenal endoscopic submucosal dissection is associated with an increased risk of intraprocedural perforation and delayed adverse events. Duodenal endoscopic submucosal dissection should be limited to endoscopists with extensive experience in performing endoscopic submucosal dissection in other locations. It is strongly suggested that endoscopists in the United States refrain from performing duodenal endoscopic submucosal dissection during the early phase of their endo...

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's‐related neoplasia

“…Despite the widespread use of ESD in the East, Western adoption of the ESD technique has been lukewarm. This is likely secondary to the perceived increased risk of complications, concerns regarding procedure duration and a steeper learning curve …”

“…These initial experiences with ESD in Barrett's neoplasia have prompted some authorities in the US and Europe to recommend ESD for large lesions (>1.5 cm,) and/or for lesions with findings suspicious for submucosal involvement (failure to lift or abnormal endoscopic appearance) …”

“…Our results add to the evidence that supports the use of ESD for the treatment of Barrett's neoplasia . The nature of EMR limits the endoscopist's ability to accurately and consistently control the depth of resection and ESD has been suggested as an alternative that allows for better visualization of depth of both the lesion and resection plane . Unfortunately, direct comparisons between ESD and EMR for the treatment of Barrett's neoplasia are limited to relatively small studies or extrapolations from treatment of superficial squamous cell carcinoma of the esophagus .…”

“…Endoscopic submucosal dissection was originally developed in Japan for resection of early gastric neoplasia . Numerous publications extoll the excellent safety and efficacy of ESD, and secondarily the use of ESD has now expanded throughout the gastrointestinal tract . Despite the widespread use of ESD in the East, Western adoption of the ESD technique has been lukewarm.…”

Bleeding after endoscopic submucosal dissection of gastric lesions

“…Endoscopic submucosal dissection (ESD) is a well‐developed and effective therapeutic strategy for gastric mucosal and submucosal lesions . ESD originated from Japan, and in recent years it has gradually been adopted in other Asian countries as well as in the West . Compared with traditional endoscopic mucosal resection, ESD has a higher overall resection and cure rates of gastrointestinal neoplastic lesions, which can reduce the local recurrence rates .…”