Can we simplify terminology in the endoscopic treatment of superficial gastrointestinal neoplasia? Yes, we can.

We have read with great interest the papers by Cao et al. [1] and Yoshida et al. [2] on the outcomes of mucosectomy and submucosal dissection of early colorectal neoplasia. The proliferation of different definitions (“mucosectomy,” “submucosectomy,” “submucosal dissection” etc.), in our opinion, has generated some confusion, almost as if they referred to different procedures. We believe that it might be useful to refer to these procedures using the single term of “endoscopic resection.” This term should comprehensively include all the different terminologies adopted to date, from polypectomy to submucosal dissection, which, indeed, do merely represent diverse technical modalities for performing the same procedure.

Our position reflects three assumptions.

1. Radical resection of an early neoplastic lesion (R0 – both lateral and vertical margins free of disease) should provide the pathologist with an operative specimen that includes both mucosa and submucosa. In fact, it is only by examining both parietal layers that the pathologist can correctly stage the depth of neoplastic infiltration as intraepithelial, intramucosal or submucosal. Therefore, considering endoscopic mucosal resection and endoscopic submucosal dissection (ESD) as distinct procedures, able to obtain different depths of resection (mucosectomy = excision of mucosa, and submucosectomy = excision of mucosa and submucosa) is conceptually wrong, as both techniques aim to remove both wall layers in order to satisfy the true diagnostic and/or therapeutic intent.

2. The higher perforation rate with ESD is related to the usually larger size of the lesion and multiplicity of endoscopic cuts, and not to a different depth of resection. The injection of fluids to “expand” the areolar tissue of the submucosa to reduce the risk of transmural burn and perforation is required in both techniques as a safety pre-requisite. Whether resection is then completed with snares or with special dissecting devices (knives, needles, hydrodissectors) is only a technical note dictated by the need (or willingness) to remove “en bloc” larger lesions thus avoiding piecemeal resection.

3. The analogy to surgery: the term “anterior resection” identifies a well-codified procedure in which the rectosigmoid is excised along with the mesorectum, no matter how it is performed (laparoscopically, retro-rectal blunt dissection or bipolar scissors, manual or mechanical anastomosis). The same can be said for endoscopic hemostasis, where the adoption of injective, thermal or mechanical modalities does not change the substance of our intervention.

Therefore, the unified term of “endoscopic resection” could be used, possibly followed by technical specification of the device used (resection by snare, by knife, or by … the next trick), in order to simplify terminology and uniform description of procedures.

Competing interests: None

References

• 1 Yoshida N, Wakabayashi N, Kanemasa K. et al . Endoscopic submucosal dissection for colorectal tumors: technical difficulties and rate of perforation.  Endoscopy. 2009;  41 758-761
• 2 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;  41 751-757