Endoscopy 2006; 38(10): 978-979
DOI: 10.1055/s-2006-944833
Introduction
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic submucosal dissection (ESD) section: An overview of articles in this issue

T.  Rösch1
  • 1Central Interdisciplinary Endoscopy, Virchow Hospital Campus, Charité Hospitals, Berlin, Germany
Further Information

Publication History

Publication Date:
20 October 2006 (online)

This issue of ”Endoscopy” contains a series of articles highlighting different aspects of the technique of endoscopic submucosal dissection (ESD) in the treatment of selected gastric tumors (early gastric cancers and a minority of gastric adenomas). ESD was developed to enable operators to resect lesions en bloc, even the larger ones, in contrast to the conventional technique of endoscopic mucosal resection (EMR), which is often performed piecemeal, resulting in difficulties in making a histopathological assessment of the completeness of resection.

The articles include three large series as well as smaller series in which technical modifications were made to the technique, such as the use of an external grasping forceps or a new, two-channel endoscope (the “R-scope”) with the facility for up/down and lateral movements of both channels. The main outcome parameters of the studies that concentrated on stomach tumors are summarized in Table [1]. The studies used a variety of knives (see the individual papers for details) and the majority used solutions other than saline (glycerol, sodium hyaluronate, and fructose).

Table 1 Summary of the studies on endoscopic submucosal dissection of gastric tumors. The procedural data relate to lesions, not patients Author (journal page number) and technique No. of patients No. of lesions Lesion size ± SD (range), mm Procedure time (range), minutes En-bloc + R0 resection rate, % Rate of major complications, % Conventional endoscope Kakushima et al., p. 991 Imagawa et al., p. 987 Onozato et al., p. 980 334 185160 383 196171 19 (3 - 85) 17 (5 - 70)24 ± 13 80 (8 - 600) 68 (10 - 400)80 (10 - 600) 91 % 84 %94 % 7.3 % (bleeding 3.4 %; perforation 3.9 %)6.1 % (all perforations)7.6 % (all delayed bleeding) Technical modifications Imaeda et al.: external grasping forceps, p. 1007 Yonezawa et al., p. 1011 R-scope Neuhaus et al.: R-scope, p. 1016 25 20 10 25 20 10 15 (10 - 25) 18 ± 10 22 (20 - 45) 45 (30 - 85) 58 ± 30 78 (40 - 200) 100 % 95 % 100 % 0 5 % (bleeding 2.5 %; perforation 2.5 %)20 % (all perforations)

The studies show that within a reasonable time (around 1 hour), although usually still longer than for EMR, the rate for one-piece R0 resection is around 90 % for this technique. Complications occured in about 5 % of cases but almost all of these, even perforations, could be managed conservatively. A very high success rate was also achieved by ESD in the treatment of local recurrences after EMR in a small series of 15 cases, with a complete resection rate of 83 % and no perforations (Oka et al., p. 996). The degree of technical difficulty of ESD is considerable, though larger lesions were resectable in shorter time periods after some 50 cases (Kakushima et al., p. 991). This may also explain why Western results are less good (Neuhaus, p. 1016), despite the use of a new double-channel endoscope, which performed better in Japanese hands (Yonezawa et al., p. 1011).

If perforations do occur, they can mostly be clipped: in a compilation group of 27 cases of upper and lower gastrointestinal perforations (5 % of all cases treated), it was reported that it was always possible to treat this complication conservatively, even the three cases of delayed perforation (Fujishiro, p. 1001).

In this issue of the journal, there is also a report of ESD used to treat 12 submucosal gastric tumors (with a mean size of just over 2 cm), with a 75 % success rate (Lee et al., p. 1024). Finally, there is a report of a small series of five squamous-cell cancers of the esophagus treated by piecemeal EMR using the new multiband ligator resection system, in which extensive resection led to the development of strictures which had to be treated by bougienage (Seewald et al., p. 1029).

The articles are accompanied by an editorial (p. 1044).

T. Rösch, M. D.

Zentrale Interdisziplinäre Endoskopie · Charité Universitätsmedizin Berlin · Campus Virchow-Klinikum

Augustenburger Platz 1 · 13353 Berlin · Germany ·

Fax: +49-30-450-553902

Email: thomas.roesch@charite.de

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