Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer

Abstract

Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.

Keywords: Colorectal cancer; Complications; Endoscopic submucosal dissection; Esophageal cancer; Gastrectomy; Gastric cancer; Laparoscopic surgery; Lymph node metastasis; Perforation.

Figure 1

Image of Endoscopic submucosal dissection: Marking is not necessary in a colorectal case because the lesion margins are clear.

Figure 2

Algorithm for the treatment of early gastrointestinal tumors. ¹Perforation or bleeding during endoscopic submucosal dissection which can not be treated endoscopically or delayed perforation; ²See Table 2.

Figure 3

Resection of a rectal tumor. A: Transanal resection; B: Transanal endoscopic microsurgery.

Figure 4

A case of a rectal tumor resected by endoscopic submucosal dissection in which laparotomy was required. A: A broad-based tumor spreading to over half of the circumference is observed in the rectum; B: Chromoendoscopy with indigo carmine; C: Mucosal incision with the Flush knife; D: Appearance of the mucosa after complete resection by endoscopic submucosal dissection; E: The fixed resected specimen was 115 mm in diameter.

Figure 5

Combination of endoscopic submucosal dissection and laparoscopic surgery. A: Confirmation of tumor location and mucosal cutting around the tumor using endoscopic submucosal dissection; B: The full thickness of the stomach wall was cut using a laparoscopic instrument, such as Ligasure^®; C: The gastric wall was closed using a laparoscopic hand-sewn technique or laparoscopic suturing device, such as End-GIA.

Figure 6

Natural orifice transluminal endoscopic surgery using the endoscopic submucosal dissection technique (in a porcine model).