How Is Endoscopic Submucosal Dissection for Gastrointestinal Lesions Being Implemented? Results from an International Survey

Endoscopic submucosal dissection for early gastric cancer: A major challenge for the west

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 submucosal dissection (ESD). ESD has been widely embraced in the last decade because it allows radical en bloc resections and is associated with better outcomes, as compared to EMR. However, the lack of training opportunities and flat learning curve due to low volume of EGC cases represent major obstacles to obtain proficiency on ESD in the West. As this procedure is highly efficient for the treatment of EGC, dedicated training programs with a stepwise approach and updated guidelines for ESD embracement are needed in Western countries.

Is there a best choice of equipment for colorectal endoscopic submucosal dissection?

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a widely used technique to remove early neoplastic lesions. It was primarily used in the initial days to treat gastric lesions, but recently, the horizon of this endoscopic procedure has expanded, which has allowed us to manage other technically more complex locations, such as the colorectum.

AREAS COVERED

There has been an exponential growth regarding the wide range of devices available in the market for performing colorectal ESD. As a result, the aim of this review is to highlight the indication of this endoscopic technique, which device is best suited for which indication, as well as future trajectories in this field.

EXPERT OPINION

Although some devices have proven to be more advantageous than others in this area, very often the choice is still subjective, which is commonly attributed to individual preferences and experience. However, an accurate knowledge of the available tools and their functioning, with their pros and cons, is fundamental for any endoscopist venturing into the field of third space endoscopy. In this way, one can choose which device best suits a particular situation, along with simultaneously having the wealth of knowledge related to therapeutic armamentarium at our disposal in the endoscopy suite.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Endoscopic submucosal dissection: a country dissemination experience and outcomes

OBJECTIVE

An increasing use of endoscopic submucosal dissection (ESD) has been reported in Western countries, although some differences in training schemes and outcomes have been described. We aimed to report the training model, implementation, and outcomes of ESD in Portugal.

METHODS

All endoscopists trained at our center from our country (n = 9) were invited to a survey regarding: (a) training period; (b) ESD outcomes and (c) implementation of ESD in each respective center.

RESULTS

All endoscopists completed the survey. Learning ESD was centered on human ESD assistance in a high-volume center during a median time of 6 months and complemented mainly by hands-on courses (89%). During the surveyed period, a total of 1229 ESD were performed, mostly in gastric locations (74%). Median complete R0 and curative resection rate were 92% (IQR, 81-96.8) and 87% (IQR, 74-93.3), respectively, and median perforation rate was 0.89% (IQR, 0.25-6.22). The main limitations encountered during the implementation of ESD were related to the lack of initial mentoring or insufficient expertise to progress to more difficult lesions.

CONCLUSION

Learning ESD through participation in hands-on courses and visiting high-volume centers seems to be adequate to achieve a good competence at the initial stage of ESD, which in fact is in consonance with the European Society of Gastrointestinal Endoscopy recommendations. However, mentoring is essential for technical progression, and this represents the fundamental barrier during the adoption of ESD, which may be overcome by increasing hands-on training in animal or artificial simulators, but preferably with the implementation of a structured training program.

A survey of physician training and credentialing in endoscopic submucosal dissection in the United States

BACKGROUND

Endoscopic submucosal dissection (ESD) is technically challenging, has a longer learning curve and a greater complication rate than most new endoscopic procedures. Formal training and credentialing guidelines for ESD are currently lacking in the United States (US).

AIM

To survey ESD experts across the US to determine their learning process and obtain their opinion on how training and credentialing for ESD should develop.

DESIGN

Anonymous electronic survey.

SUBJECTS

ASGE members who are practicing US endoscopists.

METHODS

The survey was developed by iterative revisions of questions administered to three investigators who have been performing ESD for > 5 years. The final survey was distributed electronically to US endoscopists who had previously attended ESD expert conferences.

RESULTS

Thirty-five (58.3%) of 60 practicing ESD experts responded to the survey. A majority (91%) were in university-based, community, or tertiary care hospitals. All practitioners practiced on porcine explants and observed live ESD procedures as part of the training. Out of the participants, 75.8% received formal supervised hands-on training on porcine explants and/or humans before performing ESD independently. Fifty percent indicated that their facility had written guidelines specifically for ESD credentialing. Four out of 5 felt that credentialing requirements should include attending weekend ESD courses, observing live procedures, practicing on explants, and advanced endoscopic training in interventional endoscopy such as an additional year of fellowship.

LIMITATIONS

Survey completion rate of 58.3%.

CONCLUSION

ESD training should include practicing on explants, observation of live procedures, training in interventional endoscopy, and attending educational courses. Credentialing guidelines for ESD based on expert opinion need to be developed in the US.

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.

Intramucosal duodenal adenocarcinoma concomitant with Saint’s triad

Duodenal tubulovillous adenomas are rare and have malignant potential. Their successful management depends on the preoperative diagnosis and adequate excision. Endoscopic mucosal resection or submucosal dissection can control superficial tumors. Adenocarcinoma of the duodenum may originate in tubular or tubulovillous adenoma, and possible diagnostic challenges occur concerning the endoscopic biopsy findings. We report a 62-year-old female with chronic epigastric burning and a bolus sensation. Upper gastrointestinal endoscopy showed a non-ampullary duodenal tumor, and the biopsy study diagnosed a tubulovillous adenoma. Further mucosectomy revealed an intramucosal adenocarcinoma in a tubulovillous adenoma with a tumor-free pedicle. Besides the intestinal neoplasms, the patient had the diagnosis of classical Saint’s triad; and the manifestations were hiatus hernia, gallbladder disorder, and colonic diverticula. The objective is to report two scarcely described conditions and comment on controversial points of view about the concomitance of Saint’s triad and malignancy. Case reports can reduce late diagnosis, enhancing the suspicion index on rare diseases.

Implementation of endoscopic submucosal dissection in a country with a low incidence of gastric cancer: Results from a prospective national registry

Introduction

Endoscopic submucosal dissection (ESD) has become the treatment of choice for early gastric malignancies. In recent years, the ESD technique has been implemented in Western countries with increasing use.

Objectives

To describe the results of gastric ESD in a Western country with a low incidence of gastric cancer.

Patients and Methods

The prospective national registry was conducted over 4 years in 23 hospitals, including 30 endoscopists. Epithelial and subepithelial lesions (SEL) qualified to complete removal with ESD were assessed. The technique, instruments, and solution for submucosal injection varied at the endoscopist's discretion. ESD was defined as difficult when: en‐bloc resection was not achieved, had to be converted to a hybrid resection, lasted more than 2 h or an intraprocedural perforation occurred. Additionally, independent risk factors for difficult ESD were analyzed.

Results

Two hundred and thirty gastric ESD in 225 patients were performed from January 2016 to December 2019 (196 epithelial and 34 SEL). Most lesions were located in the lower stomach (111; 48.3%). One hundred and twenty‐eight (55.6%) ESD were considered difficult. The median procedure time was 105 min (interquartile range [IQR]: 60–150). The procedure time for SEL was shorter than for epithelial lesions (90 min [45–121] vs. 110 min [62–160]; p = 0.038). En‐bloc, R0, and curative resection rates were 91.3%, 75.2%, and 70.9%, respectively. Difficult ESD had lower R0 resection rates than ESD that did not meet the difficulty criteria (64.8% and 87.6%; p = 0.000, respectively). Fibrosis and poor maneuverability were independent factors associated with difficult ESD (OR 3.6, 95%CI 1.1–11.74 and OR 5.07, 95%CI 1.6–16.08; respectively).

Conclusions

Although the number of cases is limited, the results of this analysis show acceptable en‐bloc and R0 rates in gastric ESD considering the wide variability in experience among the operators. Fibrosis and poor maneuverability were associated with more difficulty in completing ESD.

Summarize the established knowledge on this subject

Endoscopic submucosal dissection (ESD) is the standard of care for treatment of early gastric cancers (GC). Due to a lower incidence of GC in European countries, the introduction of gastric ESD has been more gradual than in the East.

ESD complications, technical and clinical success depend on the endoscopist's experience, the presence of submucosal fibrosis or invasive cancer, and poor access location.

What are the significant and/or new findings of this study?

This study shows the results from a prospective nationwide registry of gastric ESD in a low GC incidence country. Despite a relative low number of cases, quite acceptable outcomes (en‐bloc, R0 and curative resection of 91.3%, 75.2% and 70.9%, respectively) were observed considering the wide variability in experience among the operators.

Difficult ESD were mainly associated with the presence of submucosal fibrosis and poor maneuverability; however, independent pre‐procedural factors were not identified. There was a trend of association between ESD difficulty and the location of the lesion in the upper/middle stomach

Endoscopic submucosal dissection (ESD): how do Western endoscopists value animal models?

INTRODUCTION

Endoscopic Submucosal Dissection (ESD)was introduced in the West later than in the East. Our aim was to assess how Western endoscopists performing ESD have been trained and how they value animal models for training.

MATERIAL AND METHODS

An online survey regarding training in ESD was sent to Western endoscopists who published articles on advanced resection techniques.

RESULTS

From 279 endoscopists, 58 (21%) completed the questionnaire, of which 50 confirmed performance of clinical ESD. Endoscopists had a median of 15 years of endoscopic experience (IQR 9.75-20.25) and all of them were performing conventional EMR, before starting ESD. Prior to clinical ESD, 74% (n = 37) underwent training with ex vivo models, 84% (n = 42) with live animal models and 92% (n = 46) with at least, one of the two models. After starting clinical ESD, as trainers, 52% (n = 26) were involved with ex vivo and 60% (n = 30) with live animal models. Personal usefulness of ex vivo and live animal models was rated with a median of 9 (IQR 8-10) and 10 (IQR 8-10), out of 10, respectively. Courses with ex vivo and live animal models were considered a prerequisite before clinical practice by 84% (n = 42) and 78% (n = 39), respectively.

CONCLUSIONS

Western endoscopists have extensive endoscopic experience before starting ESD. The majority had pre-clinical training with ex vivo and live animal models and more than half are acting as trainers of other endoscopists with these models. Animal models are considered very useful and deemed a prerequisite before clinical practice by the majority of the endoscopists.

IS ENDOSCOPIC SUBMUCOSAL DISSECTION STILL LIMITED TO FEW TERTIARY CENTERS IN THE WEST? RESULTS FROM A NATIONAL SURVEY IN BRAZIL

BACKGROUND

Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers.

OBJECTIVE

This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED).

METHODS

In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided.

RESULTS

A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers.

CONCLUSION

ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.