Introduction of endoscopic submucosal dissection in the West

Table 7 Caveats for the endoscopic submucosal dissection pioneer

Start clinical ESD only after extensive pre-clinical training

Start with easier lesions

Avoid “unprincipled ESD”

Record and monitor closely outcomes and complications- consider registry and videos

Be familiar with techniques for endoscopic management of complications

The main complications (perforation and bleeding) can almost always be managed (or even prevented in the case of bleeding) by skillful application of clips and coagulation

Experience with endoscopic clip placement and coagulation grasper application is essential (experience with endoscopic suturing is highly desirable)

Avoid mistakes in selecting and scheduling cases-many referral reports lack detailed information on morphology, size, location, prior manipulation

Morphology (e.g., Paris classification) may suggest a more advanced lesions that was appreciated on the index endoscopy and biopsy that may require expedited scheduling

Index biopsies may be misleading (obtained from the periphery rather than depressed areas of 2c or 1s lesions missing a carcinoma)

Biopsies yielding only dysplasia may result in a publicly delayed resection of cancer

Concordance of biopsy results and ultimate post-resection pathology is fair at best

EDUCATE your referring physicians-AVOID inappropriate India ink tattooing and “partial snare resections”/hot forceps/jumbo forceps for “diagnosis or “attempted” hasty resections (tackling lesions where probability of complete EMR is low)

Lack of experience in delineating early GI cancer main lead to excessive sampling biopsies

DISCOURAGE APC to” vaporize “grossly” evident residual tumor or aggressive/many biopsies of delicate flat lesions (SSA’s)

ENCOURAGE: (1) detailed descriptions: size, morphology; (2) lots of pictures; (3) giving print out with color pictures to the patient and d) having referring physicians transit “money” shots of lesion to you

Put post - resection specimens on corkboard and educate pathologist about specifics of resection

Pathologists should properly orient specimens with ≤ 2 mm slices

Pathology report should comment on adequacy of resection including deep and lateral margins with measurement of submucosal invasion with micrometer measurements as well as the differentiation (G1-G3)

Optimally there should be desmin staining of the muscularis mucosa noting the pattern of SM invasion, e.g., budding

Comment should be made regarding lymphovascular invasion with elastin Van Gieson stain to delineate venules and the D2 – 40 immunostain for lymphatics (important)

Multidisciplinary input and communication including nursing, technicians, anesthesiologists, surgeons and oncologists

The patient should be evaluated as dictated by medical history by internists, cardiology and pulmonary medicine with particular attention to anticoagulants and antiplatelet drugs

Ergonomic considerations are given to both ESD operator and patient

ESD: Endoscopic submucosal dissection; GI: Gastrointestinal.