Published online Jul 27, 2024. doi: 10.4240/wjgs.v16.i7.1965
Revised: April 26, 2024
Accepted: May 15, 2024
Published online: July 27, 2024
Processing time: 143 Days and 16.7 Hours
Gastric cancer (GC) is the 5th most common cancer and the 3rd most common cause of cancer mortality worldwide. Two main endoscopic resective techniques exist for early GC (EGC): Endoscopic mucosal resection (EMR) and endoscopic sub
Core Tip: Endoscopic submucosal dissection (ESD) is a highly efficient treatment mo
- Citation: Schlottmann F. Endoscopic submucosal dissection for early gastric cancer: A major challenge for the west. World J Gastrointest Surg 2024; 16(7): 1965-1968
- URL: https://www.wjgnet.com/1948-9366/full/v16/i7/1965.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v16.i7.1965
Gastric cancer (GC) is the 5th most common cancer and the 3rd most common cause of cancer mortality worldwide[1]. However, Eastern countries such as China, Korea or Japan have significantly higher incidence of the disease, and GC represents one of the leading causes of cancer-related mortality[2]. Although systemic therapies with chemotherapy and immunotherapy have evolved overtime, resective treatment (endoscopically or surgically) remains the cornerstone of curative treatment[3].
Gastrectomy for cancer is a procedure associated with relatively high morbidity, especially in low volume centers[4]. For instance, in two previous European randomized trials mortality rates after D2 gastrectomy reached up to 10.0% and 13.0%[5,6]. A recent study analyzed 67389 patients undergoing oncologic gastric resection in Germany between 2008 and 2018; 5.2% of patients had anastomotic leakage and mortality occurred in 6.7% of cases after total gastrectomy[7]. An Asian trial conducted by experienced surgeons in 24 specialized centers with high volume of cases also showed high mor
Early GC (EGC) includes tumors confined to the mucosa (T1a) or submucosa (T1b). Intramucosal tumors with a size less than 2 cm, well differentiated, without ulceration, and without lymphovascular invasion have very low risk of lymph node metastasis (1%-5%). For this reason, current guidelines recommend endoscopic resection as first line treatment for early tumors meeting these criteria[9,10]. Two main endoscopic resective techniques exist: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is a relatively simple procedure which is widely adopted and allows for both pathologic diagnosis and treatment by complete resection. ESD has been embraced in the last decade as one of the main therapies for EGC because it allows dissection of the entire lesion along with radical en bloc resections. However, this technique is considered technically more difficult and is potentially associated with higher complication rates.
A recent study has compared efficacy and safety between EMR (n = 39) and ESD (n = 39) for the treatment of EGC and precancerous lesions in elderly patients (> 65 years old). The curative resection rates (74% vs 51%) and en bloc resection rates (97% vs 71%) were significantly higher with ESD (P = 0.001). Intraoperative bleeding was higher and operative time longer with ESD, as compared to EMR. Oncological outcomes (1-year postoperative recurrence rates and 3-year survival rates) were significantly better after ESD[11]. Other studies have also shown the superiority of ESD over EMR for EGC[12-14]. For instance, a previous meta-analysis comprising 10 studies with 4328 Lesions (1916 ESD and 2412 EMR) con
Based on the current evidence, ESD should be the selected endoscopic procedure for resection of EGC. However, the adoption of ESD in Western countries poses two main challenges: Low prevalence of EGC and lack of training/expertise in such advanced endoscopic techniques. Current population-based screening guidelines in Japan recommend biennial GC screening via upper gastrointestinal series or upper endoscopy for individuals older than 50 years old[15]. Nation
The low number of patients with EGC in most Occidental countries ultimately precludes the appropriate training and expertise on ESD. A previous study evaluated the learning curve for ESD performed by a single operator at a high-vo
Overall, ESD is a less invasive alternative to surgery for the treatment of EGC. However, a deficient ESD poses higher risks of procedure-related complications, as well as higher risk of incomplete oncologic resections. This complex en
An Italian center described their training strategy for adopting skills before performing ESD. The learning process included: visiting a high-volume center in Tokyo for 3 months observing at least 3-5 complete procedures per day, initial practice on isolated pig stomachs, and finally performing ESD in 3 patients with EGC under direct and strict supervision of the expert[23]. The European Society of Gastrointestinal Endoscopy guidelines also propose an ESD training algorithm for Western endoscopists which includes: Knowledge acquisition of techniques, instrumentation and electrosurgical endoscopic equipment by self-study, practice on animal models (explanted organs and live animal models), observing experts performing ESD (4-5 wk) in referral centers, hands-on workshops with expert guidance, and starting with ESD in humans on very selected cases (e.g., small lesion in the lower part of the stomach)[24]. Novel gastric ESD non-animal training models have been recently described that appear to significantly improve skills of inexperienced ESD trainees[25]. Finally, the development of flexible robotic systems for ESD will potentially help reducing the technical challenges of ESD and shortening the learning curve of inexperienced endoscopists[26].
ESD is a complex endoscopic procedure that requires extensive training and considerable endoscopic skills. As this procedure is highly efficient for the treatment of EGC, dedicated training programs with a stepwise approach and up
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