Endoscopic submucosal dissection in the era of proton pump inhibitors

Abstract

Endoscopic submucosal dissection (ESD) has the advantage over endoscopic mucosa resection, permitting removal of gastrointestinal neoplasms en bloc, but is associated with relatively high risk of complications. Indications for early gastric cancer (EGC) are expanded: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings </=3 cm in diameter; and minute submucosal invasive cancer </=3 cm in size. The indications for early esophageal cancer (EEC) are the tumors confined to the two-third layer of the lamina propria. The EEC lesions spreading more than three-quarter of circumference of the esophagus are at frequent risk of stenosis. The procedures include marking, submucosal injection, circumferential mucosal incision and exforiation of the lesion along the submucosal layer. Complete ESD can achieve a large one-piece resection, allowing precise histological assessment to prevent recurrence. Clinical outcomes of gastric and esophageal ESD have been promising, and the prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted. Notification of perforation risk is essential in particular for esophageal ESD. Bleeding during ESD can be managed with coagulation forceps, and postoperative bleeding may be reduced with routine use of the stronger acid suppressant, proton pump inhibitors.

Keywords: Barrett’s adenocarcinoma; early esophageal cancer; early gastric cancer; endoscopic submucosal dissection; proton pump inhibitor.

Fig. 1

Endoscopic submucosal dissection in a case of semicircular esophageal squamous cell carcinoma, approximately 7 cm wide. Choromoendoscopy with an iodine solution revealed the iodine unstained area spreading three-quarter of circumference of the esophagus (A). En bloc removal of the lesion was achieved in circumference (B). Resected specimen removed by ESD showed complete resection with the tumor-free margin (C).