A Single Center Experience of Endoscopic Submucosal Dissection

Abstract

Introduction: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique used for the resection of superficial gastrointestinal tumors with data showing high en bloc and curative resection rates in early gastric cancer. While it has been widely employed in East Asia, its adoption in the West has been slow due to the increased technical difficulty, higher rate of complications, longer procedure times and lower candidate populations. Methods: A retrospective review of the clinical and technical characteristics of ESD for superficial lesions of the gastrointestinal tract treated at Mount Sinai Beth Israel Medical Center, New York between May 2012 and December 2016. Results: We reviewed 59 cases of ESD - 46 gastric, 7 esophageal and 6 colorectal lesions. There were 21 cases of early malignancy, all in the upper GI tract (20 gastric, 1 esophageal). The overall en bloc resection rate was 70% (15/21) and R0 resection rate was 85% (18/21). Among the early gastric cancers, 7 were adenocarcinomas without invasion beyond the submucosa (T1), 3 were intramucosal carcinomas and 10 were cases of high grade dysplasia (HGD). There were 8 cases of low grade dysplasia with endoscopically-visible mucosal abnormalities, all of which were en bloc R0 resections. Eleven of the cases of gastric ESD were for submucosal tumors - 5 GISTs, 3 carcinoid tumors, 1 leiomyoma and 2 pancreatic rests. The seven esophageal lesions were 3 granular cell tumors, 2 dysplastic lesions in the setting of Barrett's esophagus, one case of HGD and one case of lymphoepithelioma-like carcinoma (curative R0 resection). Six of these cases were en bloc resections. Complete resection of 6 colorectal polyps were performed by ESD. Two of these polyps had previously undergone partial mucosal resection limiting en bloc resection. The average procedure time in the esophagus, stomach and colon was 76, 106 and 83 minutes respectively. The average resection sizes were 2, 3 and 2 cm respectively. There was one complication, in a patient who underwent ESD in the proximal stomach for a lesion with LGD, of delayed bleeding requiring hospitalization and endoscopic therapy. Conclusion: In this small single center series, ESD appears to be effective and safe with resection rates comparable to published data. With further experience, specialized training and development of dedicated instruments, ESD should become integrated into specialized endoscopic practice in the West for the treatment of GI tract neoplasms.