Endoscopic Submucosal Dissection of Early Gastric Cancer

Abstract

Endoscopic mucosal resection (EMR) of early gastric cancer (EGC) without any risk of lymph node metastasis was developed in Japan in the 1980s, and it has been one of the standard treatments of EGC for nearly 20 years. Recently, several EMR techniques developed in Japan have been accepted and done in Western countries. These EMR techniques are safe and efficacious but unsuitable for large lesions. Because we could not remove a large lesion in 1 fragment, which was very important for the precise diagnosis of tumor depth, local recurrence increased in large-lesion cases. An innovative procedure using newly developed endoscopic knives, called endoscopic submucosal dissection (ESD), was developed in the late 1990s, which made it possible to remove a large lesion en bloc. Theoretically, ESD has no limitation with respect to tumor size; therefore, it is expected to replace the surgical treatment in some situations. Although ESD has spread throughout Japan within a short period, there remain several disadvantages, such as a higher incidence of complications and a requirement of higher endoscopic skills compared to those of conventional EMR methods. The endoscopic indications, procedures, complications and treatment outcomes of the ESD of EGC are described in this review.

Laparoscopic gastrectomy after incomplete endoscopic resection for early gastric cancer

“…It is apparent that ER causes burn, fibrosis, and adhesion of the stomach and surrounding tissue because of electrical coagulation (15). Although we experienced non-physiological adhesion around the tumor in patients with previous ESD, we did not encounter critical difficulties such as severe adhesions and anatomical misidentification during LAG.…”

Training in endoscopic submucosal dissection

“…Endoscopic submucosal dissection (ESD) was developed in Japan in the late 1990s as an advanced, minimally invasive technique for endoscopic removal of early gastric cancers [1][2][3][4][5] . En-bloc resection with standard endoscopic mucosal resection (EMR) techniques is limited to lesions less than 2 cm in diameter, while ESD yields a higher complete resection regardless of size.…”

“…En-bloc resection with standard endoscopic mucosal resection (EMR) techniques is limited to lesions less than 2 cm in diameter, while ESD yields a higher complete resection regardless of size. EMR remains the typical approach in Western countries to treat dysplastic lesions and early cancers [6][7][8][9] while in Asia, ESD has become the preferred therapeutic modality of superficial tumors in both the upper and lower gastrointestinal tract [3] . It is even considered that it brought about a renaissance of therapeutic endoscopy [10] as it is able to offer organ-sparing cure in patient with early gastrointestinal (GI) cancers [11] .…”

“…It is even considered that it brought about a renaissance of therapeutic endoscopy [10] as it is able to offer organ-sparing cure in patient with early gastrointestinal (GI) cancers [11] . ESD has been a significant advancement in therapeutic endoscopy with its major advantages being the ability to achieve a higher en-bloc resection rate, accurate histological evaluation and lower cancer recurrence rates compared to EMR [3,[12][13][14][15] . In addition, ESD enables enbloc removal of previously unresectable lesions, such as large mucosal tumors, tumors with scars and submucosal fibrosis, or recurrent tumors after EMR [16,17] .…”

Can we apply the same indication of endoscopic submucosal dissection for primary gastric cancer to remnant gastric cancer?

“…Endoscopic submucosal dissection (ESD) now permits complete resection for more larger and deeper tumors without piecemeal resection [2]. Consequently, ESD has extended the indications for endoscopic tumor resection in the absence of evidence for lymph node (LN) metastasis [3][4][5].…”