THE RED SECTION
nature publishing group
see related editorial on page x
Indications and Techniques for Endoscopic Submucosal Dissection Amit Bhatt, MD1, Seiichiro Abe, MD2, Arthi Kumaravel, MD1, John Vargo, MD, MPH1 and Yutaka Saito, MD, PhD2
Endoscopic submucosal dissection (ESD) allows for curative resection of superficial neoplasms of the gastrointestinal tract. Although ESD is the standard of care in Japan, its adoption in the West has been slow. Recent studies have shown the advantages of ESD over endoscopic mucosal resection, and as many of the barriers to ESD have been overcome, we are seeing an increasing interest in this technique. ESD can be used to treat superficial gastric, esophageal, and colorectal lesions. The most important pre-procedure step is estimating the depth of invasion of a lesion and by proxy the risk of lymph node metastasis. After a lesion has been resected, the histopathological analysis will determine whether the resection was curative or whether further surgery is needed. In conclusion, ESD is being more widely used in the West, and it is important to understand the indications, limitations, and techniques of ESD. Am J Gastroenterol advance online publication, 27 January 2015; doi:10.1038/ajg.2014.425
Introduction
Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows for curative resection of superficial neoplasms in the gastrointestinal tract. It is able to achieve en bloc margin-negative resection of tumors while avoiding invasive surgery and allowing preservation of the native organ (1–3). Its advantage over traditional endoscopic mucosal resection (EMR) is in its ability to achieve en bloc resection of lesions >2 cm, and avoiding piecemeal resection that is associated with local recurrence (4). By achieving en bloc resection, it allows for the detailed histopathologic assessment that is necessary to confirm curative resection (Figure 1). ESD is able to resect superficial lesions regardless of tumor size, location, and fibrosis (1–3). These advantages come at the cost of an increased risk of perforation, bleeding, and a longer procedure time as compared with EMR (5). ESD was developed over 10 years ago in Japan, and it has now become the standard of care there for the treatment of superficial gastrointestinal neoplasms (6,7). The vast majority of experience and guidelines for ESD resection comes from Japan. It is important to understand the indications and limitations of ESD so that patients are appropriately triaged to either ESD or surgery. The indications, equipment, technique, and complications will be reviewed below.
Indications
The major curative difference between surgical and endoscopic resection of cancer is the absence of lymph node dissection with endoscopic resection. Thus, endoscopic resection can only be
considered in lesions with a negligible risk of lymph node metastasis or a risk less than the mortality associated with its surgical counterpart. The risk of lymph node metastasis is largely based on a tumor’s depth of invasion, and hence a large part of the preprocedure evaluation is estimating a lesion’s depth of invasion. Endoscopic evaluation of the depth of invasion varies by the location of the tumor. The true depth of invasion is not known until pathologic analysis of the resected specimen, and thus it is important to understand what high-risk histopathologic findings would necessitate surgery after ESD.
Stomach
Gastric cancer is one of the most common cancers in Japan, and owing to their national screening programs, >50% of gastric cancers are diagnosed as early gastric cancer (EGC) (8–10). Analysis of a large series of gastrectomy specimens with EGC revealed that certain groups of EGC patient had a negligible risk of lymph node metastasis on the basis of histology, ulceration, size, lymphovascular involvement, and depth of invasion (11,12). These groups are ideal candidates for endoscopic resection, and they make up the criteria for the Japanese Gastric Cancer Treatment Guidelines (Table 1) (13,14). Gastric pre-procedure estimation of depth of invasion is based on the lesion’s macroscopic type, endoscopic features, and high-frequency probe-based endosonographic examination (15). The macroscopic type is based on the Japanese Classification of Gastric Carcinoma or the Paris classification that is more commonly known in the West (16,17).
1
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA; 2Endoscopy Division, National Cancer Center, Hospital, Tokyo, Japan. Correspondence: Amit Bhatt, MD, Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A30, Cleveland, Ohio 44195, USA. E-mail: [email protected]
© 2015 by the American College of Gastroenterology
The American Journal of GASTROENTEROLOGY
1
2
THE RED SECTION
Esophagus
The anatomy of the esophageal wall differs significantly from the rest of the gastrointestinal tract in that the lymphatics penetrate the muscularis mucosa and there is higher risk of lymph node metastasis even with early cancer (18). However, this risk must be weighed against the risks of esophagectomy that carries a mortality rate of ∼ 1–6% (19–22). In addition, the narrow lumen of the esophagus is prone to stricture formation (23). Weighing these factors the Japanese Esophageal Society Guidelines absolute indication for esophageal ESD are intramucosal cancers involving the epithelium and lamina propria occupying 30 colonic ESDs under expert supervision is recommended before independent practice (48,49). However, this is difficult to attain in the United States where the volume of human gastric ESD procedures is not as high as in Japan, and expert guidance is not commonly available. Studies regarding learning curves of Western endoscopists in the animal model are needed to better define competency. Equipment. Appropriate equipment is necessary for successful ESD. In addition to the previously described equipment, high-performance electrosurgical generators are needed to The American Journal of GASTROENTEROLOGY
provide the modulated currents necessary for ESD. The commonly used high-performance electrosurgical generators are the ERBE VIO 200S (ERBE, Tuebingen, Germany), ERBE VIO 300D (ERBE), and ESG 100 (Olympus, Center Valley, PA). Electrosurgical generator settings for ESD vary by technique, instrument type, location, and nature of the lesion, and they may need to be adjusted during ESD based on the final tissue effect. To understand electrosurgical generator settings for ESD, one should contact the manufacturer of their generator. Commercially available ESD knives in the United States include IT knife 2 (Olympus KD-611L, Japan), Dual Knife (Olympus KD-650L/U, Japan), Hook knife (Olympus KD-620LR/UR Japan), IT knife nano (Olympus KD-612L/U, Japan), FlexKnife (Olympus www.amjgastro.com
THE RED SECTION
KD-630L, Japan), Hybrid knife T-type (ERBE), and Hybrid knife I-type (ERBE).
American Society for Gastrointestinal Endoscopy Cook Medical Don Wilson Award 2013.
Performing in human cases. Appropriate case selection is paramount, and we believe that this is best achieved in a multidisciplinary approach with the involvement of gastroenterologists, surgeons, and oncologists. The various treatment options of ESD, EMR, ablative therapies, and surgery can be discussed, and the most optimal treatment modality for each patient can be selected. The technical skill required for ESD varies by location, with distal gastric lesions being the easiest, followed by proximal gastric lesions. Esophageal and colonic lesions are more challenging and are attempted by Japanese endoscopists only after gaining competency in gastric lesions. EGC is rare in the West, and this smooth progression is not possible. The most common lesions available in the West are esophageal and colonic lesions. We find that ESD of flat rectal polyps is the best starting point in the West. Most lesions that are appropriate for ESD in the West are currently being treated by piecemeal EMR or surgery, and we hope that as understanding and awareness of ESD grows, more of these cases will be referred for ESD. Precise histopathologic analysis of resected specimens is the last but essential step necessary to assess resection margins, risk of lymph node involvement, and to decide whether curative resection was achieved or additional therapy is warranted. Our institutions have adopted the handling and analysis of resected specimens as outlined in the Japanese Classification of Gastric Carcinoma guidelines and the JSCCR (Japanese Society for Cancer of the Colon and Rectum) guidelines (16,50).
REFERENCES
CONCLUSION
In Japan, ESD has become the standard of care for the treatment of superficial neoplasms of the gastrointestinal tract. Adoption of this technique in the West has been slow owing to the previous lack of availability of specialized devices, low case volume, and its flat learning curve. Many of these barriers have now been overcome. A sufficient number of ESD devices have been approved in the United States to allow for successful ESD practice. Although EGC is rare in the United States, extension of the ESD technique to the esophagus and colon allows us to address diseases that are more common in the West. A number of western endoscopists have now spent time training in Japan and are proficient in the procedure. Although ESD has been successfully adopted in Japan, western diseases, biology, and environment are significantly different than Japan. 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 EAC and flat colonic polyps. CONFLICT OF INTEREST The authors declare no conflict of interest. ACKNOWLEDGMENTS This study was supported by the American College of Gastroenterology North American International Training Grant 2012, and the
© 2015 by the American College of Gastroenterology
1. Gotoda T, Ho KY, Soetikno R et al. Gastric ESD: current status and future directions of devices and training. Gastrointest Endosc Clin N Am 2014;24:213–33. 2. Draganov PV, Gotoda T, Chavalitdhamrong D et al. Techniques of endoscopic submucosal dissection: application for the Western endoscopist? Gastrointest Endosc 2013;78:677–88. 3. Ono S, Fujishiro M, Koike K. Endoscopic submucosal dissection for superficial esophageal neoplasms. World J Gastrointest Endosc 2012;4: 162–6. 4. Cao Y, Liao C, Tan A et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009;41:751–7. 5. Oda I, Suzuki H, Nonaka S et al. Complications of gastric endoscopic submucosal dissection. Dig Endosc 2013;25((Suppl 1)):71–8. 6. Hirao M, Masuda K, Asanuma T et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic salineepinephrine. Gastrointest Endosc 1988;34:264–9. 7. Gotoda T, Kondo H, Ono H et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc 1999;50:560–3. 8. Nakamura K, Ueyama T, Yao T et al. Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy. Cancer 1992;70:1030–7. 9. Oda I, Saito D, Tada M et al. A multicenter retrospective study of endoscopic resection for early gastric cancer. Gastric Cancer 2006;9:262–70. 10. Shimizu S, Tada M, Kawai K. Early gastric cancer: its surveillance and natural course. Endoscopy 1995;27:27–31. 11. Yamao T, Shirao K, Ono H et al. Risk factors for lymph node metastasis from intramucosal gastric carcinoma. Cancer 1996;77:602–6. 12. Gotoda T, Yanagisawa A, Sasako M et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 2000;3:219–25. 13. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113–23. 14. Hirasawa T, Gotoda T, Miyata S et al. Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer 2009;12:148–52. 15. Abe S, Oda I, Shimazu T et al. Depth-predicting score for differentiated early gastric cancer. Gastric Cancer 2011;14:35–40. 16. Japanese Gastric Cancer A. Japanese classification of gastric carcinoma 2nd English edition -. Gastric Cancer 1998;1:10–24. 17. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003;58:S3–43. 18. Rice TW, Bronner MP. The esophageal wall. Thorac Surg Clin 2011;21: 299–305. 19. Markar SR, Karthikesalingam A, Thrumurthy S et al. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg 2012;16:1055–63. 20. Liu L, Hofstetter WL, Rashid A et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005;29:1079–85. 21. Li Z, Rice TW, Liu X et al. Intramucosal esophageal adenocarcinoma: primum non nocere. J Thorac Cardiovasc Surg 2013;145:1519–24. 1524.e1-3. 22. Dunbar KB, Spechler SJ. The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review. Am J Gastroenterol 2012;107:850–62 quiz 863. 23. Katada C, Muto M, Manabe T et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003;57:165–9. 24. Kuwano H, Nishimura Y. Guidelines for diagnosis and treatment of carcinoma of the esophagus. Esophagus 2008;5:61–73. 25. Kumagai Y, Inoue H, Nagai K et al. Magnifying endoscopy, stereoscopic microscopy, and the microvascular architecture of superficial esophageal carcinoma. Endoscopy 2002;34:369–75. 26. Saito Y, Fukuzawa M, Matsuda T et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colo-
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rectal tumors as determined by curative resection. Surg Endosc 2010;24: 343–52. 27. Saito Y, Otake Y, Sakamoto T et al. Indications for the technical aspects of colorectal endoscopic submucosal dissection. Gut Liver 2013;7: 263–9. 28. Uraoka T, Saito Y, Matsuda T et al. Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut 2006;55:1592–7. 29. Nakajima T, Saito Y, Tanaka S et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013;27:3262–70. 30. Nakamura F, Saito Y, Sakamoto T et al. Potential perioperative advantage of colorectal endoscopic submucosal dissection versus laparoscopy-assisted colectomy. Surg Endosc 2015 e-pub ahead of print. 31. Matsuda T, Fujii T, Saito Y et al. Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms. Am J Gastroenterol 2008;103:2700–6. 32. Ikematsu H, Matsuda T, Emura F et al. Efficacy of capillary pattern type IIIA/IIIB by magnifying narrow band imaging for estimating depth of invasion of early colorectal neoplasms. BMC Gastroenterol 2010;10:33–230X10-33 33. Kudo S, Hirota S, Nakajima T et al. Colorectal tumours and pit pattern. J Clin Pathol 1994;47:880–5. 34. Hayashi N, Tanaka S, Hewett DG et al. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification. Gastrointest Endosc 2013;78:625–32. 35. Sanchez-Yague A, Kaltenbach T, Yamamoto H et al. The endoscopic cap that can (with videos). Gastrointest Endosc 2012;76:169–78.e1-2. 36. Uraoka T, Saito Y, Yamamoto K et al. Submucosal injection solution for gastrointestinal tract endoscopic mucosal resection and endoscopic submucosal dissection. Drug Des Devel Ther 2009;2:131–8. 37. Yamamoto H, Kawata H, Sunada K et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003;35:690–4. 38. Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the upper GI tract. Hook knife EMR method. Minim Invasive Ther Allied Technol 2002;11:291–5.
The American Journal of GASTROENTEROLOGY
39. Yahagi N, Fujishiro M et al. Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type). Dig Endosc 2004;16:34–8. 40. Ono H, Hasuike N, Inui T et al. Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer. Gastric Cancer 2008;11:47–52. 41. Saito Y, Kawano H, Takeuchi Y et al. Current status of colorectal endoscopic submucosal dissection in Japan and other Asian countries: progressing towards technical standardization. Dig Endosc 2012;24:67–72. 42. Uedo N, Takeuchi Y, Yamada T et al. Effect of a proton pump inhibitor or an H2-receptor antagonist on prevention of bleeding from ulcer after endoscopic submucosal dissection of early gastric cancer: a prospective randomized controlled trial. Am J Gastroenterol 2007;102:1610–6. 43. Minami S, Gotoda T, Ono H et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596–601. 44. Ikehara H, Gotoda T, Ono H et al. Gastric perforation during endoscopic resection for gastric carcinoma and the risk of peritoneal dissemination. Br J Surg 2007;94:992–5. 45. Coda S, Oda I, Gotoda T et al. Risk factors for cardiac and pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment. Endoscopy 2009;41:421–6. 46. Yamaguchi N, Isomoto H, Nakayama T et al. Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2011;73:1115–21. 47. Hanaoka N, Ishihara R, Takeuchi Y et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012;44:1007–11. 48. Oda I, Odagaki T, Suzuki H et al. Learning curve for endoscopic submucosal dissection of early gastric cancer based on trainee experience. Dig Endosc 2012;24:129–32. 49. Sakamoto T, Saito Y, Fukunaga S et al. Learning curve associated with colorectal endoscopic submucosal dissection for endoscopists experienced in gastric endoscopic submucosal dissection. Dis Colon Rectum 2011;54:1307–12. 50. Watanabe T, Itabashi M, Shimada Y et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol 2011;17:1–29.
www.amjgastro.com
nature publishing group
see related editorial on page x
Indications and Techniques for Endoscopic Submucosal Dissection Amit Bhatt, MD1, Seiichiro Abe, MD2, Arthi Kumaravel, MD1, John Vargo, MD, MPH1 and Yutaka Saito, MD, PhD2
Endoscopic submucosal dissection (ESD) allows for curative resection of superficial neoplasms of the gastrointestinal tract. Although ESD is the standard of care in Japan, its adoption in the West has been slow. Recent studies have shown the advantages of ESD over endoscopic mucosal resection, and as many of the barriers to ESD have been overcome, we are seeing an increasing interest in this technique. ESD can be used to treat superficial gastric, esophageal, and colorectal lesions. The most important pre-procedure step is estimating the depth of invasion of a lesion and by proxy the risk of lymph node metastasis. After a lesion has been resected, the histopathological analysis will determine whether the resection was curative or whether further surgery is needed. In conclusion, ESD is being more widely used in the West, and it is important to understand the indications, limitations, and techniques of ESD. Am J Gastroenterol advance online publication, 27 January 2015; doi:10.1038/ajg.2014.425
Introduction
Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows for curative resection of superficial neoplasms in the gastrointestinal tract. It is able to achieve en bloc margin-negative resection of tumors while avoiding invasive surgery and allowing preservation of the native organ (1–3). Its advantage over traditional endoscopic mucosal resection (EMR) is in its ability to achieve en bloc resection of lesions >2 cm, and avoiding piecemeal resection that is associated with local recurrence (4). By achieving en bloc resection, it allows for the detailed histopathologic assessment that is necessary to confirm curative resection (Figure 1). ESD is able to resect superficial lesions regardless of tumor size, location, and fibrosis (1–3). These advantages come at the cost of an increased risk of perforation, bleeding, and a longer procedure time as compared with EMR (5). ESD was developed over 10 years ago in Japan, and it has now become the standard of care there for the treatment of superficial gastrointestinal neoplasms (6,7). The vast majority of experience and guidelines for ESD resection comes from Japan. It is important to understand the indications and limitations of ESD so that patients are appropriately triaged to either ESD or surgery. The indications, equipment, technique, and complications will be reviewed below.
Indications
The major curative difference between surgical and endoscopic resection of cancer is the absence of lymph node dissection with endoscopic resection. Thus, endoscopic resection can only be
considered in lesions with a negligible risk of lymph node metastasis or a risk less than the mortality associated with its surgical counterpart. The risk of lymph node metastasis is largely based on a tumor’s depth of invasion, and hence a large part of the preprocedure evaluation is estimating a lesion’s depth of invasion. Endoscopic evaluation of the depth of invasion varies by the location of the tumor. The true depth of invasion is not known until pathologic analysis of the resected specimen, and thus it is important to understand what high-risk histopathologic findings would necessitate surgery after ESD.
Stomach
Gastric cancer is one of the most common cancers in Japan, and owing to their national screening programs, >50% of gastric cancers are diagnosed as early gastric cancer (EGC) (8–10). Analysis of a large series of gastrectomy specimens with EGC revealed that certain groups of EGC patient had a negligible risk of lymph node metastasis on the basis of histology, ulceration, size, lymphovascular involvement, and depth of invasion (11,12). These groups are ideal candidates for endoscopic resection, and they make up the criteria for the Japanese Gastric Cancer Treatment Guidelines (Table 1) (13,14). Gastric pre-procedure estimation of depth of invasion is based on the lesion’s macroscopic type, endoscopic features, and high-frequency probe-based endosonographic examination (15). The macroscopic type is based on the Japanese Classification of Gastric Carcinoma or the Paris classification that is more commonly known in the West (16,17).
1
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA; 2Endoscopy Division, National Cancer Center, Hospital, Tokyo, Japan. Correspondence: Amit Bhatt, MD, Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A30, Cleveland, Ohio 44195, USA. E-mail: [email protected]
© 2015 by the American College of Gastroenterology
The American Journal of GASTROENTEROLOGY
1
2
THE RED SECTION
Esophagus
The anatomy of the esophageal wall differs significantly from the rest of the gastrointestinal tract in that the lymphatics penetrate the muscularis mucosa and there is higher risk of lymph node metastasis even with early cancer (18). However, this risk must be weighed against the risks of esophagectomy that carries a mortality rate of ∼ 1–6% (19–22). In addition, the narrow lumen of the esophagus is prone to stricture formation (23). Weighing these factors the Japanese Esophageal Society Guidelines absolute indication for esophageal ESD are intramucosal cancers involving the epithelium and lamina propria occupying 30 colonic ESDs under expert supervision is recommended before independent practice (48,49). However, this is difficult to attain in the United States where the volume of human gastric ESD procedures is not as high as in Japan, and expert guidance is not commonly available. Studies regarding learning curves of Western endoscopists in the animal model are needed to better define competency. Equipment. Appropriate equipment is necessary for successful ESD. In addition to the previously described equipment, high-performance electrosurgical generators are needed to The American Journal of GASTROENTEROLOGY
provide the modulated currents necessary for ESD. The commonly used high-performance electrosurgical generators are the ERBE VIO 200S (ERBE, Tuebingen, Germany), ERBE VIO 300D (ERBE), and ESG 100 (Olympus, Center Valley, PA). Electrosurgical generator settings for ESD vary by technique, instrument type, location, and nature of the lesion, and they may need to be adjusted during ESD based on the final tissue effect. To understand electrosurgical generator settings for ESD, one should contact the manufacturer of their generator. Commercially available ESD knives in the United States include IT knife 2 (Olympus KD-611L, Japan), Dual Knife (Olympus KD-650L/U, Japan), Hook knife (Olympus KD-620LR/UR Japan), IT knife nano (Olympus KD-612L/U, Japan), FlexKnife (Olympus www.amjgastro.com
THE RED SECTION
KD-630L, Japan), Hybrid knife T-type (ERBE), and Hybrid knife I-type (ERBE).
American Society for Gastrointestinal Endoscopy Cook Medical Don Wilson Award 2013.
Performing in human cases. Appropriate case selection is paramount, and we believe that this is best achieved in a multidisciplinary approach with the involvement of gastroenterologists, surgeons, and oncologists. The various treatment options of ESD, EMR, ablative therapies, and surgery can be discussed, and the most optimal treatment modality for each patient can be selected. The technical skill required for ESD varies by location, with distal gastric lesions being the easiest, followed by proximal gastric lesions. Esophageal and colonic lesions are more challenging and are attempted by Japanese endoscopists only after gaining competency in gastric lesions. EGC is rare in the West, and this smooth progression is not possible. The most common lesions available in the West are esophageal and colonic lesions. We find that ESD of flat rectal polyps is the best starting point in the West. Most lesions that are appropriate for ESD in the West are currently being treated by piecemeal EMR or surgery, and we hope that as understanding and awareness of ESD grows, more of these cases will be referred for ESD. Precise histopathologic analysis of resected specimens is the last but essential step necessary to assess resection margins, risk of lymph node involvement, and to decide whether curative resection was achieved or additional therapy is warranted. Our institutions have adopted the handling and analysis of resected specimens as outlined in the Japanese Classification of Gastric Carcinoma guidelines and the JSCCR (Japanese Society for Cancer of the Colon and Rectum) guidelines (16,50).
REFERENCES
CONCLUSION
In Japan, ESD has become the standard of care for the treatment of superficial neoplasms of the gastrointestinal tract. Adoption of this technique in the West has been slow owing to the previous lack of availability of specialized devices, low case volume, and its flat learning curve. Many of these barriers have now been overcome. A sufficient number of ESD devices have been approved in the United States to allow for successful ESD practice. Although EGC is rare in the United States, extension of the ESD technique to the esophagus and colon allows us to address diseases that are more common in the West. A number of western endoscopists have now spent time training in Japan and are proficient in the procedure. Although ESD has been successfully adopted in Japan, western diseases, biology, and environment are significantly different than Japan. 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 EAC and flat colonic polyps. CONFLICT OF INTEREST The authors declare no conflict of interest. ACKNOWLEDGMENTS This study was supported by the American College of Gastroenterology North American International Training Grant 2012, and the
© 2015 by the American College of Gastroenterology
1. Gotoda T, Ho KY, Soetikno R et al. Gastric ESD: current status and future directions of devices and training. Gastrointest Endosc Clin N Am 2014;24:213–33. 2. Draganov PV, Gotoda T, Chavalitdhamrong D et al. Techniques of endoscopic submucosal dissection: application for the Western endoscopist? Gastrointest Endosc 2013;78:677–88. 3. Ono S, Fujishiro M, Koike K. Endoscopic submucosal dissection for superficial esophageal neoplasms. World J Gastrointest Endosc 2012;4: 162–6. 4. Cao Y, Liao C, Tan A et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009;41:751–7. 5. Oda I, Suzuki H, Nonaka S et al. Complications of gastric endoscopic submucosal dissection. Dig Endosc 2013;25((Suppl 1)):71–8. 6. Hirao M, Masuda K, Asanuma T et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic salineepinephrine. Gastrointest Endosc 1988;34:264–9. 7. Gotoda T, Kondo H, Ono H et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc 1999;50:560–3. 8. Nakamura K, Ueyama T, Yao T et al. Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy. Cancer 1992;70:1030–7. 9. Oda I, Saito D, Tada M et al. A multicenter retrospective study of endoscopic resection for early gastric cancer. Gastric Cancer 2006;9:262–70. 10. Shimizu S, Tada M, Kawai K. Early gastric cancer: its surveillance and natural course. Endoscopy 1995;27:27–31. 11. Yamao T, Shirao K, Ono H et al. Risk factors for lymph node metastasis from intramucosal gastric carcinoma. Cancer 1996;77:602–6. 12. Gotoda T, Yanagisawa A, Sasako M et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 2000;3:219–25. 13. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113–23. 14. Hirasawa T, Gotoda T, Miyata S et al. Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer 2009;12:148–52. 15. Abe S, Oda I, Shimazu T et al. Depth-predicting score for differentiated early gastric cancer. Gastric Cancer 2011;14:35–40. 16. Japanese Gastric Cancer A. Japanese classification of gastric carcinoma 2nd English edition -. Gastric Cancer 1998;1:10–24. 17. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003;58:S3–43. 18. Rice TW, Bronner MP. The esophageal wall. Thorac Surg Clin 2011;21: 299–305. 19. Markar SR, Karthikesalingam A, Thrumurthy S et al. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg 2012;16:1055–63. 20. Liu L, Hofstetter WL, Rashid A et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005;29:1079–85. 21. Li Z, Rice TW, Liu X et al. Intramucosal esophageal adenocarcinoma: primum non nocere. J Thorac Cardiovasc Surg 2013;145:1519–24. 1524.e1-3. 22. Dunbar KB, Spechler SJ. The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review. Am J Gastroenterol 2012;107:850–62 quiz 863. 23. Katada C, Muto M, Manabe T et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003;57:165–9. 24. Kuwano H, Nishimura Y. Guidelines for diagnosis and treatment of carcinoma of the esophagus. Esophagus 2008;5:61–73. 25. Kumagai Y, Inoue H, Nagai K et al. Magnifying endoscopy, stereoscopic microscopy, and the microvascular architecture of superficial esophageal carcinoma. Endoscopy 2002;34:369–75. 26. Saito Y, Fukuzawa M, Matsuda T et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colo-
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