ADVERTISEMENT

A minimally invasive treatment for early GI cancers

Cleveland Clinic Journal of Medicine. 2017 September;84(9):707-717 | 10.3949/ccjm.84a.16063
September 1, 2017|Cleveland Clinic Journal of Medicine
Lady Katherine Mejía-Pérez, MD;Seiichiro Abe, MD;Tyler Stevens, MD;Mansour A. Parsi, MD;Sunguk N. Jang, MD;Ichiro Oda, MD;John J. Vargo, MD, MPH;Yutaka Saito, MD, PhD;Amit Bhatt, MD
Author and Disclosure Information

Lady Katherine Mejía-Pérez, MD
Department of Internal Medicine, Cleveland Clinic

Seiichiro Abe, MD
Endoscopy Division, National Cancer Center Hospital,  Tokyo, Japan

Tyler Stevens, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Mansour A. Parsi, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

Sunguk N. Jang, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

Ichiro Oda, MD
Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

John J. Vargo, MD, MPH
Chairman, Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Yutaka Saito, MD, PhD
Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

Amit Bhatt, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Amit Bhatt, MD, Department of Gastroenterology and Hepatology, Digestive Disease Institute, A30, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; bhatta3@ccf.org

ABSTRACT

Endoscopic submucosal dissection (ESD) allows curative resection of early malignant gastrointestinal (GI) lesions, potentially avoiding open surgery. Unfortunately, awareness of this technique is low, and many patients undergo surgery without consideration of ESD. This article reviews the indications for ESD and its advantages and limitations, and guides internists in their approach to patients with early GI cancer.

KEY POINTS

  • ESD is a minimally invasive endoscopic technique with curative potential for patients with superficial GI neoplasia.
  • ESD preserves the integrity of the organ while achieving curative resection of large neoplasms.
  • ESD is indicated rather than surgery in patients with early GI lesions with a negligible risk of lymph node metastasis.
  • Complications of the procedure include bleeding, perforation, and stenosis. Most of these respond to endoscopic treatment.
  • Successful ESD requires supportive teamwork among internists, gastroenterologists, pathologists, and surgeons.

LIMITATIONS OF ESD

ESD requires a high level of technical skill, is time-consuming, and has a higher rate of complications than conventional endoscopic resection. A standardized ESD training system is needed, as the procedure is more difficult than EMR. Training in porcine models has been shown to confer competency in ESD in a Western setting.13,16,33

Colorectal ESD is an even more challenging procedure, given the potential for complications related to its anatomy. Training centers in Japan usually have their trainees first master gastric ESD, then assist in more than 20 colorectal ESDs conducted by experienced endoscopists, and accomplish 30 cases before performing the procedure safely and independently.

As the incidence of gastric cancer is low in Western countries, trainees may also begin with lower rectal lesions, which are easier to remove.77 Incorporation of ESD in the West would require a clear treatment algorithm. It is a complex procedure, with higher rates of complications, a prolonged learning curve, and prolonged procedure time. Therefore, it should be performed in specialized centers and under the special situations discussed here to ensure that the benefits for the patients outweigh the risks.

VALUE OF ENDOSCOPIC SUBMUCOSAL DISSECTION

The optimal method for resecting gastrointestinal neoplasms should be safe, cost-effective, and quick and should also completely remove the lesion. The best treatment strategy takes into account the characteristics of the lesion and the comorbidities and wishes of the patient. Internists should be aware of the multiple options available to achieve the best outcome for the patient.1

Endoscopic resection of superficial gastrointestinal neoplasms, including EMR and ESD, has been a subject of increasing interest due to its minimally invasive and potentially curative character. However, cancer can recur after endoscopic resection because the procedure is organ-sparing.

ESD allows resection of early gastrointestinal tumors with a minimally invasive technique. It can achieve higher curative resection rates and lower recurrence rates compared with EMR. Compared with surgery, ESD leads to less morbidity, fewer procedure-related complications, and lower medical costs. Indications should be rigorously followed to achieve successful treatments in selected patients.

Multiple variables have to be taken into account when deciding which treatment is best, such as tumor characteristics, the patient’s baseline condition, physician expertise, and hospital resources.48 Less-invasive treatments may improve the prognosis of patients. No matter the approach, patients should be treated in specialized treatment centers.

Internal medicine physicians should be aware of the advances in treatments for early gastrointestinal cancer so appropriate options can be considered.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT