Takuji Gotoda, MD, PhD, FASGE, FACG, FRCP
The ideal resection technique for any given lesion in the gastrointestinal (GI) tract depends on several factors, including the invasiveness of the procedure, whether the “completeness” of a resection translates into clinical benefits that outweigh the risks of the procedure, and whether alternate treatments are suitable and available.1–3 While surgery has traditionally been the standard of care for the management of neoplastic lesions in the GI tract, advances in endoscopic techniques have led to a paradigm shift in how we approach many of these disease processes.
Over the past several decades, we have witnessed the birth and evolution of multiple endoscopic resection techniques for the treatment of superficial GI neoplasia. The first endoscopic resection technique reported was in the form of colorectal polypectomy using electrocautery.4 Shortly thereafter, this technique was adopted and first described in Japan in 1974 for the management of both pedunculated and semi-pedunculated early gastric cancer.5 Subsequently, nearly a decade later, the “strip biopsy” technique was introduced as an application of endoscopic snare polypectomy.6 To further optimize the amount of resected material for pathological staging while limiting collateral tissue injury, a technique called endoscopic resection with local injection of hypertonic saline epinephrine solution was introduced in 1988.7 In the following years, modified techniques of endoscopic mucosal resection (EMR), including both a cap-fitted panendoscope method and a band-assisted approach were developed.8,9 The main advantages of the cap- and band-assisted EMR techniques included the ability to create “pseudopolyps” for the simple and safe resection of flat lesions. Conversely, the main limitation of EMR techniques was the inability to en bloc resect lesions larger than 20 mm,10,11 which often required piecemeal removal. This in turn limited accurate pathological assessment and also increased the risk of local cancer recurrence.12,13
The development of improved endoscopic electrosurgical knives paved the way for advanced endoscopic resection techniques and our ability to resect lesions en bloc, irrespective of size. The electrosurgical insulated-tip diathermic knife, developed in the 1990s at the National Cancer Center Hospital in Japan, is a prime example of innovations that arose from troubleshooting the limitations of standard EMR techniques for the treatment of early gastric cancer. This insulated-tip knife permitted free-hand endoscopic dissection of the submucosa for en bloc resection of lesions, leading to the term endoscopic submucosal dissection (ESD).2-4 Since its initial introduction, advances in ESD over the years has permitted the complete en bloc resection of lesions regardless of tumor size, location, and/or presence of submucosal fibrosis.5 Hence, nowadays ESD has become a widely acceptable minimally invasive option for the management superficial GI neoplasia.6 The well-recognized benefits of ESD include (1) the provision of an adequate specimen for accurate histopathological staging without precluding future surgery if indicated, (2) as an alternative strategy for nonsurgical candidates because of medical comorbidities, and (3) its curative potential for lesions with no or low risk for lymphatic involvement.
We have continued to see major strides in safety and efficacy of minimally invasive endoscopic approaches with ongoing advances in therapeutic endoscopy. In this book, we provide an in-depth analysis of the current state of advanced endoscopic techniques for the evaluation and resection in the GI tract. Each chapter in this book addresses specific topics, ranging from the endoscopic evaluation of lesions and technical aspects of the procedure to management of adverse events and postresection surveillance. The chapters are structured to be read either independently or together, depending on the reader’s background and interest. Introductory and background information is reinforced across chapters to build a firm understanding of concepts when approaching the book as a whole, and to prevent the need to flip back and forth between chapters when selecting individual topics to reference. We hope this book will serve as a favored resource for readers seeking a comprehensive understanding of techniques and procedures that have become standard protocol for treating lesions in the GI tract.
1. Gotoda T, Yang HK. The desired balance between treatment and curability in treatment planning for early gastric cancer. Gastrointest Endosc. 2015;82(2):308-310. doi:10.1016/j.gie.2015.02.050.
2. Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut. 2001;48(2):225-229.
3. Hosokawa K, Yoshida S. Recent advances in endoscopic mucosal resection for early gastric cancer [in Japanese]. Gan To Kagaku Ryoho [Jpn J Cancer Chemother]. 1998;25(4):476-483.
4. Gotoda T, Kondo H, Ono H, et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc. 1999;50(4):560-563.
5. Yokoi C, Gotoda T, Hamanaka H, Oda I. Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection. Gastrointest Endosc. 2006;64(2):212-218. doi:10.1016/j.gie.2005.10.038.
6. Probst A, Schneider A, Schaller T, Anthuber M, Ebigbo A, Messmann H. Endoscopic submucosal dissection for early gastric cancer: are expanded resection criteria safe for Western patients? Endoscopy. 2017;49(9):855-865. doi:10.1055/s-0043-110672.
7. Hirao M, Masuda K, Asanuma T, et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine. Gastrointest Endosc. 1988;34(3):264-269.
8. Inoue H, Takeshita K, Hori H, Muraoka Y, Yoneshima H, Endo M. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc. 1993;39(1):58-62.
9. Akiyama M, Ota M, Nakajima H, Yamagata K, Munakata A. Endoscopic mucosal resection of gastric neoplasms using a ligating device. Gastrointest Endosc. 1997;45(2):182-186.
10. Korenaga D, Haraguchi M, Tsujitani S, Okamura T, Tamada R, Sugimachi K. Clinicopathological features of mucosal carcinoma of the stomach with lymph node metastasis in eleven patients. Br J Surg. 1986;73(6):431-433.
11. Ell C, May A, Gossner L, et al. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus. Gastroenterology. 2000;118(4):670-677.
12. Tanabe S, Koizumi W, Mitomi H, et al. Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer. Gastrointest Endosc. 2002;56(5):708-713. doi:10.1067/mge.2002.129085.
13. Kim JJ, Lee JH, Jung HY, et al. EMR for early gastric cancer in Korea: a multicenter retrospective study. Gastrointest Endosc. 2007;66(4):693-700. doi:10.1016/j.gie.2007.04.013.