Esophageal Endoscopic Submucosal Dissection

Esophageal Endoscopic Submucosal Dissection

Daniel S. Strand, MD

Andrew Y. Wang, MD

Endoscopic submucosal dissection (ESD) is a therapeutic endoscopic technique that enables the en bloc resection of superficial epithelial neoplasia within the alimentary track. Developed by Japanese endoscopists following the observation that piecemeal endoscopic mucosal resection (EMR) of large lesions resulted in appreciable rates of recurrence, the goal of ESD is the en bloc removal of superficial luminal neoplasms, including in the esophagus.1,2,3 Although adoption of ESD among Western endoscopists has been slowed by a lack of formalized training and the slow release of specialized endoscopic tools, there is significant enthusiasm for this procedure as it offers the ability to provide a curative R0 resection for large dysplastic lesions and early esophageal cancers.4,5


Establishing the depth and local extent of neoplasia is the major determinant of whether or not to perform ESD for superficial esophageal cancers, provided that the means and experience required to remove the lesion by ESD is present. Therefore, careful preprocedure assessment of any lesion considered for ESD is critical.

  • 1. Endoscopic visual assessment: High-definition white-light inspection and advanced endoscopic imaging are important for detection and assessment of prospective lesions prior
    to ESD. Advanced imaging techniques include dye-based chromoendoscopy, optical enhancement technologies (e.g., narrow-band imaging), and methods such as optical coherence tomography or confocal endomicroscopy. While review of these approaches is beyond the scope of this chapter, advanced endoscopists performing ESD should be well versed in use of dye-based and electronic chromoendoscopy. Use of endoscopes capable of optical zoom magnification can offer a diagnostic advantage, in particular when evaluating intrapapillary capillary loops (IPCLs) as a means of diagnosing and staging SCCs. Careful mucosal endoscopic examination of esophageal lesions is essential for delineation of margins, as well as identification of highly dysplastic or malignant foci, which must be removed.11 For squamous lesions, we found the topical application of a dilute 0.5% Lugol iodine solution (Safecor Health, Woburn, MA) to the esophageal mucosa prior to lesion marking very useful. This will delineate the extent of SCC, as dysplastic or malignant cells will not uptake the dilute iodine, whereas normal squamous cells will. Barrett esophagus can be surveyed after the application of acetic acid, which may facilitate the endoscopic diagnosis of high-grade intraepithelial neoplasia or cancer with a sensitivity of up to 96%.11

  • 2. Endoscopic ultrasound: EUS can be considered prior to esophageal ESD but is not mandatory. The ability of EUS to accurately discriminate endoscopic resectability (T1 vs T2) is imperfect, even when high-frequency EUS miniprobes are used. Up to 25% of lesions may be understaged by EUS, while up to 12% may be overstaged when compared to pathology.12 Despite tempered enthusiasm for EUS in T-staging, EUS using a dedicated radial or linear echoendoscope is valuable for nodal staging, and linear EUS and fine-needle aspiration should be performed if suspicious lymph nodes are identified.

May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Esophageal Endoscopic Submucosal Dissection

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