Establishing endoscopic submucosal dissection (ESD) – Learning curve experience in an Austrian referral centre

Introduction: ESD is the treatment of choice for mucosal pre-/cancers of the gastrointestinal (GI) tract. Benefits of ESD are curative resection en-bloc, conclusive histopathology, and near zero rate of local recurrence [1]. ESD was introduced in Japan, where it spreads by clinical tutoring. In Europe, however, ESD is to be established without clinical tutoring.

Aim: To introduce ESD for GI indications [1].

Methods: After extensive experimental preparation [2], a single senior endoscopist (F.B.) performed ESD on 45 successive epithelial neoplasias in the GI tract – all indications for en-bloc-resection [1]. ESD was done using dual- and/or hook-knife en-bloc (ESD), or with snaring of residual submucosa (ESD-snare)[3]. Outcome was prospectively documented.

Results: In a total of 45 flat lesions, 2 (4%) were hyperplastic, 4 (8%) adenomas without dysplasia, 44% and 42% with low and high grade dysplasia, respectively. Nine (20%) of the lesions were upper GI (3 esophagus, 1 cardia, 5 gastric, 1 duodenum), and 38 (80%) colonic (including 16% rectal). Three difficult ESD were converted to piecemeal-EMR (lesion sizes 23, 18, 12.5cm² – in rectum, ascending colon, cardia) – without recurrence in two at 9 months of follow-up, and with hemicolectomy (ascend. colon) in one. Median lesion size was 2.8cm (5.8 cm2), procedure times ranged from 25 to 355min (median 134min) – with one complicated outlier (590min). The rates were 92% for complete resection and 65% for R-0 resection. So far, there was only one recurrence one year after ESD-snare of duodenal adenoma with LGD. The rate of bleeding (transfusion of 2 units blood) was 2%, that of acute perforation 15%. One patient received hemicolectomy for inflammatory reaction after delayed clipping of retroperitoneal perforation, and one preventive resection of gastric ESD-ulcer (instead of mucosal endoclipping). There was no long-term morbidity, all patients (even after perforation) were discharged ≤10 days after ESD.

ESD	ESD snare	Piecemeal -EMR	R-0 resec.	Recurrence	Perfo- ration	Surgery	Bleeding	Median size [range] cm2
42%	51%	6.6%	65%	2%	15%	4.4%	2%	5.8 [1.2–20.3]

Discussion: With rigorous experimental ESD experience, clinical ESD may be learned in difficult locations in colon with acceptable rate of complications – this probably is indispensable considering prevalence of lesions and useful case load (˜ ≥2 ESD per month).

References: 1. Fujishiro M. World J Gastroenterol, 2008, 14:4289–4295. 2. Berr F., et al. Dig Endosc, 2011, 23:281–289.