Outweighing the benefits and weakness of endoscopic submucosal dissection for early gastric cancer in the west

Abstract

Endoscopic submucosal dissection (ESD) is believed to provide higher curability than endoscopic mucosal resection (EMR) in the treatment of early gastric cancer [1, 2]. But whether ESD can expand the indications of EMR without increasing the risk of incomplete tumor resection (R1) is controversial. In the West, significantly fewer patients than in Asian countries such as Japan and Korea receive a diagnosis of early gastric cancer (EGC). Early diagnosis not only offers an excellent prognosis but also allows a minimally invasive treatment approach that substantially improves the quality of life (QOL). The much higher incidence of EGC in East Asia explains the advances in the development of ESD and EMR. Because of the low detection rate of EGC in the West, relatively few Western institutions apply these techniques, so reports for the treatment of EGC with modern approaches are considered with interest. In the July issue of Surgical Endoscopy, Catalano and colleagues [3] reported on their experience with ESD in Verona, Italy. After experience with 36 EMRs during the initial period (2001–2005), the authors moved to ESD and reported on 12 ESD procedures between May 2005 and April 2007. Histologic examination of the resected specimens showed complete removal of the tumor (R0) in 92% of the cases compared with only 56% in the EMR group. In the ESD group, one patient experienced bleeding and perforation. During a mean follow-up period of 31 months, no patients with a pathologically confirmed complete resection experienced local or distant recurrence. The authors conclude that ESD can be performed with safety and efficacy in the Western world. This first report on ESD in the West confirms the central role of experience in achieving positive results. But whether the higher curability rate with ESD than with EMR is attributed to ESD or better selection of patients in the ESD group and a more careful approach after substantial experience with EMR is difficult to infer from this small study. A prospective study based on a protocol is required for robust conclusions. Apparently, ESD offers increased curability in one dimension (deeper gastric wall excision). However, resection in the other two dimensions is similar. Thus, the criteria for EMR in terms of tumor size, histologic type (exclusion of undifferentiated or diffuse-type cancer), and the presence of ulceration also should be met in the performance of ESD. Minimally invasive approaches, particularly endoscopic resection, provide substantially better QOL than conventional open surgery for gastrointestinal cancer. But the excellent oncologic outcomes for patients with early gastric cancer treated using open or laparoscopic gastrectomy makes essential the careful selection of patients for ESD. Excellent oncologic outcomes with ESD should be ensured with very careful patient selection. Indeed, solid evidence suggests excellent oncologic outcomes for patients with early-stage disease treated using either open or laparoscopic surgery [4–7]. Besides treatment of cancer at an early stage, quality control in surgery and multimodal adjuvant treatment can substantially improve survival rates even for patients with advanced resectable stage 2 or 3 disease [8–14]. Yet, in the Western world, open surgery still remains the standard of care for early gastric cancer. J. Spiliotis Department of Surgery, Metaxa Anticancer Hospital, Piraeus, Greece