Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts

Endoscopic submucosal dissection (ESD) is the gold standard technique for performing en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. Experience in Europe, however, is still limited and ESD is only performed in a few selected centers, with low volumes of cases, no description of training programs, and few published reports. In 2008, a panel of experts gathered in Rotterdam to discuss indications, training, and the wider use of ESD. The panel of experts and participants reached a consensus on five general statements: 1) ESD aims at treating mucosal cancer; 2) treatment aims for R0 resection; 3) ESD should meet quality standards; 4) ESD should be performed following national or European Society of Gastrointestinal Endoscopy (ESGE) guidelines or under institutional review board approval; and 5) ESD cases should be registered. Due to the high level of expertise needed to perform the technique safely, ESD should be performed in a step-up approach, starting with lesions presenting in the rectum or in the distal stomach, then colon, proximal stomach, and finally in the esophagus. Registration is advised either at the local site or at a national or ESGE level, and should include information on indication (Paris classification of lesion, location, and histological results prior to treatment), technique used (e. g. type of knife), results (en bloc and R0 resection), complications, and follow-up. The panel also agreed on minimal institutional requirements: good quality imaging, experienced histopathologist following the Japanese criteria (2-mm sections, micrometric invasion, vessel and lymphatic infiltration, etc), and dedicated endoscopic follow-up. Moreover, minimum training requirements were also defined: knowledge in indications and instruments, exposure to experts (currently all in Japan), hands-on experience in a model of isolated pig stomach and in live pigs, and management of complications. The experts did not reach a consensus on a minimum case load, or whether the technique should be restricted to expert centers.

References

• 1 Tada M, Murata M, Murakami F. Development of the strip-off (in Japanese).  Gastroenterol Endosc. 1984;  26 833-839
• 2 Inoue H, Endo M, Takeshita K. et al . Endoscopic resection of early-stage esophageal cancer.  Surg Endosc. 1991;  5 59-62
• 3 Makuuchi H, Machimura T, Soh Y. Endoscopic mucosectomy for mucosal carcinomas in the esophagus.  Jpn J Surg Gastroenterol. 1991;  24 2599-2603
• 4 Soehendra N, Binmoeller K F, Bohnacker S. et al . Endoscopic snare mucosectomy in the esophagus without any additional equipment: a simple technique for resection of flat early cancer.  Endoscopy. 1997;  29 380-383
• 5 Hawes R H. Endoscopic mucosal resection: established indications, potential indications and perspectives.  Acta Gastroenterol Belg. 2005;  68 15-18
• 6 Kodashima S, Fujishiro M, Yahagi N. et al . Endoscopic submucosal dissection using flexknife.  J Clin Gastroenterol. 2006;  40 378-384
• 7 Hirao M, Masuda K, Asanuma T. et al . Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine.  Gastrointest Endosc. 1988;  34 264-269
• 8 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;  35 690-694
• 9 Ohkuwa M, Hosokawa K, Boku N. et al . New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife.  Endoscopy. 2001;  33 221-226
• 10 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 S67-S70
• 11 Inoue H, Sato Y, Kazawa T, Kudo S. Endoscopic submucosal dissection using a triangle-tipped knife (In Japanese).  Stomach and Intestine. 2003;  39 53-56
• 12 Yahagi N, Fujishiro M, Imagawa A. Endoscopic submucosal dissection for the reliable en bloc resection of colorectal mucosal tumors.  Dig Endosc. 2004;  16 S89-S92
• 13 Jouret A, Sempoux C. Superficial oeso-gastric cancer and endoscopic mucosal resection: the pathologist’s approach.  Acta Gastroenterol Belg. 2006;  69 316-320
• 14 Kojima T, Parra-Blanco A, Takahashi H, Fujita R. Outcome of endoscopic mucosal resection for early gastric cancer: review of the Japanese literature.  Gastrointest Endosc. 1998;  48 550-554; discussion 554 – 555
• 15 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 16 Deprez P, Aouattah T, Laurent S. et al . Endoscopic resection of superficial gastric tumours: low numbers but high success rates!.  Gut. 2006;  56 A285
• 17 Deprez P, Aouattah T, Yeung C. Endoscopic resection of superficial gastric tumours. Gastrointest Endosc.  Gastrointest Endosc. 2007;  65 AB164
• 18 Neuhaus H, Costamagna G, Deviere J. et al . Endoscopic submucosal dissection (ESD) of early neoplastic gastric lesions using a new double-channel endoscope (the “R-scope”).  Endoscopy. 2006;  38 1016-1023
• 19 Catalano F, Trecca A, Rodella L. et al . The modern treatment of early gastric cancer: our experience in an Italian cohort.  Surg Endosc. 2009;  23 1581-1586
• 20 Dinis-Ribeiro M, Pimentel-Nunes P, Afonso M. et al . A European case series of endoscopic submucosal dissection for gastric superficial lesions.  Gastrointest Endosc. 2009;  69 350-355
• 21 Deprez P, Yeung R, Aouattah T. Prospective randomized comparison between EMR and ESD for endoscopic removal of superficial esophageal cancer.  Gastrointest Endosc. 2008;  67 AB187
• 22 Goto O, Fujishiro M, Kodashima S. et al . Outcomes of endoscopic submucosal dissection for early gastric cancer with special reference to validation for curability criteria.  Endoscopy. 2009;  41 118-122
• 23 Hoteya S, Iizuka T, Kikuchi D, Yahagi N. Benefits of endoscopic submucosal dissection according to size and location of gastric neoplasm, compared with conventional mucosal resection.  J Gastroenterol Hepatol. 2009;  24 1102-1106
• 24 Fujishiro M, Yahagi N, Kakushima N. et al . Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases.  Clin Gastroenterol Hepatol. 2007;  5 678-683; quiz 645
• 25 Repici A. Endoscopic submucosal dissection: established, or still needs improving?.  Gastrointest Endosc. 2009;  69 16-18
• 26 Repici A, Pellicano R, Strangio G. et al . Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes.  Dis Colon Rectum. 2009;  52 1502-1515
• 27 Piessevaux H, Dewit O, Azzouzi K. et al . Endoscopic submucosal dissection for en bloc resection of large colorectal adenomas: experience in a Western population.  Gastrointest Endosc. 2008;  67 AB149
• 28 Hurlstone D P, Shorthouse A J, Brown S R. et al . Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis.  Colorectal Dis. 2008;  10 891-897
• 29 Hurlstone D P, Atkinson R, Sanders D S. et al . Achieving R0 resection in the colorectum using endoscopic submucosal dissection.  Br J Surg. 2007;  94 1536-1542
• 30 Messmann H, Probst A. Management of endoscopic submucosal dissection complications.  Endoscopy. 2009;  41 712-714
• 31 Probst A, Golger D, Arnholdt H, Messmann H. Endoscopic submucosal dissection of early cancers, flat adenomas, and submucosal tumors in the gastrointestinal tract.  Clin Gastroenterol Hepatol. 2009;  7 149-155
• 32 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
• 33 Imagawa A, Okada H, Kawahara Y. et al . Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success.  Endoscopy. 2006;  38 987-990
• 34 Kakushima N, Fujishiro M, Kodashima S. et al . A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms.  Endoscopy. 2006;  38 991-995
• 35 Eguchi T, Gotoda T, Oda T. Is endoscopic one-piece mucosal resection essential for early gastric cancer?.  Dig Endosc. 2003;  15 113-116
• 36 Ishihara R, Iishi H, Uedo N. et al . Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan.  Gastrointest Endosc. 2008;  68 1066-1072
• 37 Kakushima N, Fujishiro M, Kodashima S. et al . Histopathologic characteristics of gastric ulcers created by endoscopic submucosal dissection.  Endoscopy. 2006;  38 412-415
• 38 Nakamoto S, Sakai Y, Kasanuki J. et al . Indications for the use of endoscopic mucosal resection for early gastric cancer in Japan: a comparative study with endoscopic submucosal dissection.  Endoscopy. 2009;  41 746-750
• 39 Oda I, Saito D, Tada M. et al . A multicenter retrospective study of endoscopic resection for early gastric cancer.  Gastric Cancer. 2006;  9 262-270
• 40 Terada N, Hamazaki T, Oka M. et al . Bone marrow cells adopt the phenotype of other cells by spontaneous cell fusion.  Nature. 2002;  416 542-545
• 41 Ono S, Fujishiro M, Niimi K. et al . Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms.  Gastrointest Endosc. 2009;  70 860-866
• 42 Gotoda T. A large endoscopic resection by endoscopic submucosal dissection procedure for early gastric cancer.  Clin Gastroenterol Hepatol. 2005;  3 S71-S73
• 43 Gotoda T, Yamamoto H, Soetikno R M. Endoscopic submucosal dissection of early gastric cancer.  J Gastroenterol. 2006;  41 929-942
• 44 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;  3 219-225
• 45 Nunobe S, Gotoda T, Oda I. et al . Distribution of the deepest penetrating point of minute submucosal gastric cancer.  Jpn J Clin Oncol. 2005;  35 587-590
• 46 Ishihara R, Iishi H, Takeuchi Y. et al . Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection.  Gastrointest Endosc. 2008;  67 799-804
• 47 Gotoda T. Endoscopic resection of early gastric cancer.  Gastric Cancer. 2007;  10 1-11
• 48 Bollschweiler E, Baldus S E, Schroder W. et al . High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas.  Endoscopy. 2006;  38 149-156
• 49 Ell C, May A, Pech O. et al . Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer).  Gastrointest Endosc. 2007;  65 3-10
• 50 Pech O, Behrens A, May A. et al . Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus.  Gut. 2008;  57 1200-1206
• 51 Fujishiro M, Yahagi N, Kakushima N. et al . Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms.  Endoscopy. 2006;  38 1001-1006
• 52 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;  94 992-995
• 53 Neuhaus H. Endoscopic submucosal dissection in the upper gastrointestinal tract: present and future view of europe.  Dig Endosc. 2009;  21 Suppl 1 S4-S6