Endoscopic mucosal resection and endoscopic submucosal dissection as treatments for early gastrointestinal cancers in Western countries

Abstract

Early gastrointestinal cancers are defined as lesions limited to the mucosa or submucosa without invading the muscularis propria, regardless of the presence of lymph node metastases. Although the natural history of these diseases is basically alike worldwide, its management is quite different between the East and West; aggressive surgery is frequently adopted by Western surgeons, while less invasive techniques are adopted by Asian colleagues. These techniques include endoscopic mucosal resection and endoscopic submucosal dissection which are now accepted as treatments for early gastrointestinal cancers in selected cases. Recent advances in endoscopic detection and treatment techniques, especially in Japan and Korea, have prompted Western endoscopists to learn these techniques. This review addresses recent advances regarding endoscopic resections of early gastrointestinal cancers, which promoted its use in Western countries. In addition, prospective studies on endoscopic resection in Western countries are also described.

Keywords: Endoscopic resection; Gastrointestinal cancer; West.

Fig. 1

Histological diagnosis of EGC. (A) A small depressed lesion is noticed on the posterior wall of upper gastric body. (B) Lesion without invasive finding is noticed on the biopsy, which is classified as dysplasia (Vienna classification 4.1.) in the West. In contrast, this lesion is classified as well differentiated adenocarcinoma (Vienna classification 4.2.) in Japan. (C) After the resection, submucosally invasive adenocarcinoma with lymphatic involvement (Vienna classification 5.2.) is diagnosed.

Fig. 2

Standard EMR methods. (A) Snare polypectomy, (B) strip biopsy, (C) EMR with cap technique, and (D) EMR with ligation technique.

Fig. 3

Endoscopic devices for ESD. (A) IT knife (KD-610L, Olympus), (B) modified IT knife with three-pointed star blade (Olympus), (C) Needle knife (KD-1L-1, Olympus), (D) Hook knife (KD-620LR, Olympus), (E) Flex knife (KD-630L, Olympus), (F) Triangle-tip knife (Olympus), (G) Flash knives with several length of needle (Fujinon Toshiba ES systems), (H) Mucosectom (DP-2518, Pentax), and (I) Small caliber tip transparent (ST) hood (DH-15GR, 15CR, Fujinon Toshiba ES systems).

Fig. 4

ESD procedures. (A) A depressed type EGC is noticed on the anterior wall of the antrum. (B) Indigo carmine dye is sprayed to detect the tumor boarder. (C) Markings are done by needle knife with coagulation current. (D) Mucosal cutting is done with IT knife using ENDO-CUT mode. (E) Dissecting submucosal layer is done by the aid of IT knife with ENDO CUT mode. Attachment cap is applied to stretch submucosal tissue. (F) A large ESD defect is noticed after complete one piece resection without perforation. (G) Flattened ESD specimen is fixed with thin needles on plate.

Fig. 5

Complications during ESD. (A) Arterial bleeding is noticed from the exfoliated submucosal layer. (B) Endoscopic hemostasis is done by capturing the bleeding vessel. (C) Perforation is noticed on the greater curvature of upper body. (D) Endoscopic closure is done by using endoclips. (E) Small perforation is noticed. (F) Pneumoperitoneum is noticed.