Is the West finally reaching the East in endoscopic submucosal dissection? The gastric cancer case

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

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.

Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice

Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.