Gastric endoscopic submucosal dissection in Western countries: Indications, applications, efficacy and training perspective

Abstract

Endoscopic submucosal dissection was introduced in Japan for the mini-invasive treatment of early gastric cancer, as part of national screening program considering high prevalence of disease in these latitudes. This technique allows en-bloc curative oncological excision and to obtain in a single step R0-resection, characterization, histological staging and potential cure of the tumor with a very high cost-benefit balance. Over the years, Western endoscopists have adopted endoscopic submucosal dissection, achieving good rates of efficacy, long-term improved outcomes and safety, with low risk of local recurrence comparable to those obtained in Asian institutes. However, according to some authors, the excellent outcomes from East country could not be representative of the Western experience. Despite epidemiological differences of early gastric cancer, scant volume data and limitations in training opportunities between Western and Eastern countries, European Society of Gastrointestinal Endoscopy have adopted Japanese guidelines and developed a European core curriculum for endoscopic submucosal dissection training. Endoscopists should be able to estimate the probability of performing a curative resection by considering the benefit/risk relationship case-by-case in order to implement a correct decision-making process.

Keywords: Endoscopic submucosal dissection, Western experience, Early gastric cancer, Curative oncological excision, Long-term outcome, Training perspective

Core Tip: In Western countries, endoscopic submucosal dissection (ESD) is an accepted first-line therapy of superficial gastric neoplasia, including dysplastic and recurrent lesions. This technique allows a high rate of curative resection and a good safety profile compared with other therapeutic approaches, including surgery, which can be reserved as a rescue therapy. Despite there certainly being some obstacles to its diffusion in the West, European Society of Gastrointestinal Endoscopy has developed a European core curriculum for ESD practice across Europe, with the aim of high quality ESD training. Probably nowadays, Western endoscopists are slowly reaching the same level of expertise and proficiency of the colleagues from the East.