Laser lithotripsy as a supplementary approach for the treatment of main pancreatic duct stones

Abstract

ESD has been systematically used to treat colorectal neoplasms for which EMR is predictably difficult because of large size, unfavorable Paris classification, or predicted submucosal invasion. 2,3 For example, differences in lesion characteristics from the large multicenter Japanese experience published by Nakajima et al 4 and depicted in Table 1 are reasonably representative of the colorectal ESD literature in general.Clearly, context is needed to interpret the fact that 7.6% of ESD patients needed further surgery as compared with 4% of EMR patients in this series. It is worth noting that essentially all patients who require further surgery after colorectal ESD have incompletely resected submucosal cancers, often because of more-extensive submucosal involvement than was predicted based on Paris classification and pit pattern evaluation using magnification chromoendoscopy. 4,5 If approximately 50% of patients require surgery after ESD of a submucosal colorectal cancer, 4,6 this is more of an indictment of the lesion selection process rather than of the therapeutic technique. Furthermore, the 50% of patients with submucosal cancers in whom a curative resection is attained with ESD may be spared surgery, a benefit that EMR can rarely offer this patient group. Because lateral margins cannot be assessed with EMR and assessment of deep margins and lymph/ vascular invasion may be hindered, piecemeal resections of malignant polyps cannot be categorized as curative. 3 This fact is reinforced by the relatively high local recurrence rate of 12.2% after EMR, compared with the low recurrence rate of .9% after ESD reported in a recent colorectal ESD meta-analysis. 5 Of note, a proportion of those patients with a local recurrence will also require further surgery.As our status evaluation report highlights, randomized controlled trials comparing ESD with competing procedures, including EMR and surgical interventions, are much needed. Also needed are additional outcomes data from Western endoscopists.