Endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a new, interventional endoscopic technique that was invented 15 years ago in Japan. The ESD technique aims at the local resection of early-stage malignant digestive tract neoplasms involving the mucosa and submucosa, and not affecting the muscular layer of the organ. It is the way to remove large early-stage cancerous or dysplastic areas, avoiding a surgical procedure.

The main advantage of the ESD technique is the accurate pathoanatomical evaluation and staging of early cancerous lesions of the digestive tract, owing to the accurate assessment of the lesion boundaries, which is not possible with piecemeal mucosectomy.

ESD is performed on early malignant lesions of the digestive tract (esophagus, stomach, colon), i.e. when the lesion is located on the mucosa or the upper layers of the submucosa. 

Polypoid and non-polypoid gastric lesions develop from the inner layer of the organ walls (mucosal) to the outer layer (submucosal, muscular, serosal). When the lesion has not infiltrated the deeper layers of the submucosa, the chance it has produced metastases is zero. Therefore, the endoscopic removal of the area effectively means the patient is cured.

The decision to endoscopically remove a suspect area requires endoscopic assessment with high-resolution magnification endoscopy, chromoendoscopy and/or ultrasound endoscopy.

With ESD, the lesion is removed in 90% to 95% of all cases, and the recurrence rate is < 2%. The boundaries of the lesion are defined and resection completeness is accurately assessed (R0 boundaries).

ESD has an advantage over endoscopic mucosectomy in that it is more successful in local resections and is associated with much lower recurrence rates. It is, however, associated with higher complication rates (bleeding, perforation) and longer examination time, as the procedure may go on for several hours, depending on the position and extent of the lesion.

The technique is performed under general anesthesia. First, the area that is to be removed is marked with a laser, using high-resolution magnification chromoendoscopy. Then the area is elevated with the injection of a suitable solution, to raise the submucosa. A circumferential incision is then performed using a special scalpel and afterwards the lesion is resected, piece by piece, through the transection of the submucosa.