Endoscopic submucosal dissection leaves its mark in Europe
The ESD technique, which originated in Japan, is being introduced in Europe. This work of medical goldsmiths has precise indications.
Among the recent developments in the treatment of colorectal lesions, Endoscopic Submucosal Dissection (ESD) is attracting increasing interest.
This minimally invasive technique, which emerged in the late 1990s, aims to resect superficial pre-cancerous and cancerous lesions located under the mucosa of the gastrointestinal tract in a single piece. It can also be used for diagnostic purposes only.
As these lesions are sometimes close to muscle tissue, ESD allows the separation of tumourous mucosa from the underlying healthy submucosa. This is a very thorough procedure, during which the endoscopist first delineates the resection margins with coagulation points.
An injection of saline or a staining solution under the mucosa then lifts it. The resection is done with a specific endoscopic electrocoagulation knife.
Japan, an example to follow
In terms of the number of procedures performed and the results, there is still a significant gap between Europe and Japan, the country of origin of ESD. The technique is much more widespread in East Asian countries (Japan, China, Korea) where the incidence of gastric cancer is particularly high.
In 2017, a study comparing Asian and non-Asian data showed that there is a clear difference between these geographical areas. For example, late bleeding, perforation or recurrence of lesions were significantly higher in the non-Asian region.
In addition, the overall rate of surgical interventions is higher in non-Asian countries, where ESD is significantly less often perceived as a treatment option.
In order to choose the optimal treatment technique, and to reduce the number of avoidable surgical interventions, a differentiated diagnosis of colorectal lesions is essential.
Different classification systems exist. The NICE classification (Narrow-Band Imaging International Colorectal Endoscopic Classification) has the advantage of being simple: it classifies colonic polyps into three categories, according to the depth of penetration under the mucosa. On the other hand, this classification is not very precise and makes it difficult to identify the patients most suitable for ESD.
The JNET (Japan Narrow-Band Imaging Expert Team) classification distinguishes between type 2A and 2B lesions. This makes it possible to better select candidates for ESD.
Recommendations in Europe
The first step is to establish, thanks to high-resolution endoscopy, a precise diagnosis of the lesion: size, morphology, location and nature. Then the classification schemes (NICE, JNET) come into play. On the basis of these criteria, it can be decided whether ESD is appropriate to treat the lesion in question.
In particular, the European Society of Gastrointestinal Endoscopy (ESGE) suggests that:
- The assessment of superficial gastrointestinal lesions be performed by an experienced endoscopist, using high-definition white light and chromoendoscopy.
- ESD should be the treatment of choice for most superficial oesophageal and gastric lesions (for lesions associated with Barrett's oesophagus, the most common pre-cancerous condition of the oesophagus, ESGE recommends ESD for lesions suspected of submucosal invasion, for malignant lesions > 20mm and for lesions in scarred/fibrotic areas).
- ESD should be considered for en bloc resection of colorectal lesions (particularly rectal) with suspected limited submucosal invasion or for lesions that cannot be completely removed by snare-based techniques.
However, the ESGE does not recommend the routine use of ESD for duodenal or small bowel lesions.
Perspectives
Europe has learned a lot from the Asian region in terms of ESD. The gap between these geographical areas has already been closed in terms of written procedures, classifications, and training curricula. The gap is gradually closing in terms of the technical proficiency, outcomes, and clinical data obtained with ESD.
Although the method is promising, it should be noted that ESD is only suitable for patients who are still in stage T1, whereas the majority of people are already in more advanced stages at the time of initial diagnosis.
Another drawback is that although the efficacy rate of curative resection is almost 50%, it is still far from the almost 100% cure rate achieved with surgical resection at stage T1.
- Fuccio L, Hassan C, Ponchon T, Mandolesi D, Farioli A, Cucchetti A, Frazzoni L, Bhandari P, Bellisario C, Bazzoli F, Repici A. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc. 2017 Jul;86(1):74-86.e17. doi: 10.1016/j.gie.2017.02.024. Epub 2017 Feb 28. PMID: 28254526.
- Ohata K, Kobayashi N, Sakai E, Takeuchi Y, Chino A, Takamaru H, Kodashima S, Hotta K, Harada K, Ikematsu H, Uraoka T, Murakami T, Tsuji S, Abe T, Katagiri A, Hori S, Michida T, Suzuki T, Fukuzawa M, Kiriyama S, Fukase K, Murakami Y, Ishikawa H, Saito Y. Long-Term Outcomes After Endoscopic Submucosal Dissection for Large Colorectal Epithelial Neoplasms: A Prospective, Multicenter, Cohort Trial from Japan. Gastroenterology. 2022 Jul 8:S0016-5085(22)00751-X. doi: 10.1053/j.gastro.2022.07.002. Epub ahead of print. PMID: 35810779.
- Endoscopic submucosal dissection for superficial gastrointestinal lesions. European Society of Gastrointestinal Endoscopy (ESGE). Guideline – Update 2022