The East in the West

---

O Oriente no Ocidente

Palavras Chave

Dissecção endoscópica da submucosa · ESD · Tracto gastrointestinal ·

---

Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the resection of early gastric lesions that is increasingly used for the removal of superficial neoplasias along the gastrointestinal tract. Contrary to endoscopic mucosal resection, ESD allows en bloc resection of lesions > 2 cm, enabling proper pathological assessment. ESD is associated with increased curative rates and reduced recurrence rates, but it is more often complicated with perforation, most of these cases being managed endoscopically. Both techniques have similar bleeding complication rates [1].

In this issue of GE – Portuguese Journal of Gastroenterology, Costa et al. [2] report on the results of 114 gastric ESDs performed in a high-volume center in Portugal. Authors found that gastric ESD is associated with en bloc resection in 96% of all cases, corresponding to R0 resections in 88%, a curative resection was obtained in 83.2%. These excellent results are re-enforced by the fact that the disease-specific survival rate at 12 months was 100%. In this study, most R1 resections were associated with positive lateral margins. That may be explained by the difficulty in delineating lesions in the stomach, where changes in the background mucosa are frequently present, but it may also be associated with the lesion’s characteristics, the nature of the endoscope used, and the ESD technique. All these parameters are prone to improvement. Early detection and proper delineation may be improved not only with the use of high-resolution endoscopes, but also by virtual or conventional chromoendoscopy. This requires optimal equipment and good endoscopic assessment and characterization skills. This work has been developed by several Portuguese gastroenterologists during the last years [3-8]. The improvement in R0 resection rates in the study by Costa et al. [2] may reflect improvements in all these factors.

In this study, complications occurred in 13.2% of all ESD procedures. This figure is slightly higher than that in most recent reports, but it reflects the learning curve process. The fact that all major complications were managed endoscopically reflects on the technique’s safety per se, on the skillful endoscopist engaged in this study, and on the close follow-up of patients by a multidisciplinary team that enabled proper and successful treatment of complications.

What May Be Expected in the Future?

Contrary to what happens in the rest of Europe and North America, there is a relatively high rate of gastric cancer and of early gastric lesions in Portugal [9]. Early gastric lesions are more prone to ESD resection due to the efficacy and safety of the technique in the stomach. In fact, the stomach is the organ used in the learning process of ESD – not only in experimental models but also in the clinical setting. In most countries in Europe and North America, the lack of early gastric lesions hampers the development of gastrointestinal ESD expertise by the fact that colonic ESD demands higher expertise and is associated with higher complication rates. So, Portugal is in the privileged situation to lead the development of gastrointestinal ESD in the West. It is expected that the good results of different Portuguese centers in gastric ESD cases will soon lead to the implementation of ESD in esophageal and colorectal superficial lesions. Portugal may be the new frontier in the development of ESD and of other advanced endoscopic techniques in the West [10]. That may be accomplished by a centralization of ESDs in high-volume centers and by a collaboration between different hospitals in order to establish the new standards on ESD in the West and to promote the development of new advanced techniques.

The future is bright!

Disclosure Statement

Author reports no disclosures related to this article.

References

---

Author Contacts

---

Article / Publication Details

---

Open Access License / Drug Dosage / Disclaimer

This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.