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Endoscopic Submucosal Dissection (ESD) is one of the most innovative and advanced techniques in the field of gastroenterology. It is a complex endoscopic method that allows the removal of large and potentially malignant lesions from the digestive tract, without the need for surgery.

ESD was first developed in Japan, mainly for the treatment of early stomach cancer. Soon, this method began to be used in other areas of the digestive system, such as the esophagus and the colon. Ultimately, the successful application and establishment of ESD worldwide remained inextricably linked to the development of endoscopic technology and endoscopic instruments. In particular, the use of high-definition endoscopes and the refinement of chromoendoscopy played a decisive role in the wider application of ESD.

What are the indications for Endoscopic Submucosal Resection (ESD)?

ESD is mainly indicated for the removal of superficial neoplasms that are difficult to remove with other endoscopic methods, such as Endoscopic Mucosal Resection (EMR).

The main indications include:

1. Early cancer of the stomach, esophagus, intestine: This category includes lesions that are limited to the first two superficial layers of the digestive system wall, have not penetrated deeply into the muscularis mucosa and do not have lymph node or distant metastases.
2. Dysplasias and precancerous lesions: Lesions that have a high probability of developing in the future to malignancies.
3. Polyps: Polyps that are difficult to remove with traditional endoscopic techniques due to size, location, fibrosis.
4. Lesions in which their total removal is deemed necessary for histopathological examination.

How is Endoscopic Submucosal Resection (ESD) performed?

ESD is a complex procedure that requires specialized equipment and interventional gastroenterologists appropriately trained in this technique. At this point, the importance of early recognition and diagnosis of early lesions must be fully understood. With the help of techniques such as artificial intelligence, chromoendoscopy and magnifying endoscopy, we are able to recognize lesions that we may not have been able to distinguish previously. Additionally, it is now possible to identify the exact boundaries of the lesions, which is of primary importance for their complete removal.

The procedure includes the following steps:

1. Identification and Marking of the lesion: The lesion is located and marked around the perimeter with the help of a special endoscopic knife.
2. Injection of Fluid Solution: A special solution containing a dye is injected into the submucosal tissue under the lesion, so as to separate it from the muscularis mucosa. Essentially, this step reduces the possibility of injury to the muscularis mucosa and, consequently, the occurrence of immediate and late complications.
3. Incision of the Mucosal: A careful circular incision of the mucosa is made around the lesion.
4. Submucosal Resection: Using specialized instruments, the submucosa is incised and the lesion is removed in its entirety.
5. Hemostasis: Visible vessels are cauterized and specific hemostasis techniques are applied to prevent bleeding.

Why is ESD advantageous over other endoscopic techniques?

ESD offers significant advantages over other methods of lesion removal, such as:

• Total removal of the lesion: ESD allows the removal of large lesions in a single piece, rather than in multiple small ones, as achieved by other techniques. This ensures definitive treatment of the lesion and reduces the risk of recurrence.
• Accurate pathological examination: Total removal of the lesion allows for complete pathological examination, facilitating accurate staging and planning of further treatment.
• Definitive treatment: With total excision of the pathological tissue, definitive treatment is achieved in over 95% of cases, provided that there are no additional risk factors. In this way, major surgeries are avoided, which significantly reduce the quality of life of patients.
• Minimization of complications: Compared to conventional surgeries, ESD proceeds with a lower risk of complications. Additionally,it minimizes and the pain for the patient and the hospital stay (1-2 days on average).

What are the possible complications and disadvantages of Endoscopic Submucosal Resection (ESD)?

Although ESD is generally safe, there are some potential complications that should be considered:

1. Bleeding (<2%): Bleeding is a complication that can occur during or after the operation. It is mainly treated purely endoscopically.
2. Perforation: Although rare (<1%), perforation of the digestive tract wall is a complication that is mainly treated endoscopically. In rare cases, the assistance of general surgery may be requested.
3. Stenosis: After ESD, strictures may occur at the site of resection, especially in the esophagus. This is especially observed in lesions that occupy more than 75% of the circulation.
4. Long duration: The removal of large lesions can be a long and time-consuming procedure, since very detailed endoscopic microsurgery is applied.
5. Trained medical personnel: ESD is a specialized technique, which is only applied by appropriately trained and experienced interventional endoscopists in this field.

Conclusion

Endoscopic Submucosal Resection (ESD) is a revolutionary method that has changed the landscape in the treatment of endoscopic lesions. It offers the possibility of removing large and complex lesions with a high success rate and low risk of complications. Despite the complexity of the procedure, the benefits of ESD make it a valuable option in the therapeutic quiver of gastroenterologists. At this point, it should be emphasized that ESD does not replace the surgeon’s role in the treatment of lesions of the digestive system. The decision on whether a lesion will be removed surgically or through invasive endoscopy is the subject of interdisciplinary consultations. It certainly constitutes an additional weapon in the treatment of early malignancies with significant advantages for the quality of life of patients.