Commentary

All too often when endoscopic submucosal dissection (ESD) is carried out, the discovery that the lesion is deeply invasive is made at the end of the procedure when considerable time and effort has been expended performing dissection and circumferential incision. This e-Video from Pioche et al. demonstrates a technique for early assessment of invasion depth by commencing the procedure with direct tunneling to the highest-risk area of the lesion. If there is clear evidence of T2 invasion into the muscularis propria the procedure is aborted and the patient is referred for surgery.

This novel approach allows endoscopists to “cut to the chase” and make an early decision to abandon or complete the procedure. It is possible that fibrosis may compromise this assessment, or that the tunnel may be off-target. It is also possible that the submucosal plane is present but less experienced operators may have difficulty separating and expanding it, thereby incorrectly classifying the lesion as deeply invasive. In any case, in the hands of these experts, this technique is a practical approach to a persistent problem. As always, examination of the performance of this diagnostic strategy in a prospective cohort will be essential to show the true sensitivity and specificity of the technique.

Publication History

Article published online:
27 July 2021