What is important for a smooth implementation of endoscopic submucosal dissection?

Endoscopic resection is the most ideal and minimally invasive treatment for superficial GI neoplasms, which are predicted to have a very low risk of lymph node metastasis. Because both patients doctors strongly desire avoid organ resection, many endoscopic techniques, including submucosal dissection (ESD), been developed. The concept ESD clear completely different from previous techniques. lateral margin ensured by incising surrounding mucosa at least few millimeters away tumor’s border, vertical also dissecting deeper part layer in ESD. This approach freehand technique; therefore, limitations on size location almost nonexistent, although it technically demanding. As result reliable en bloc allows precise histopathologic evaluation prevention local recurrence. However, this technique was initially regarded as risky procedure, even Japan, much criticized not only surgeons but gastroenterologists because increased adverse event rates. after development specific devices, such knives hemostatic forceps, accumulation knowledge about management events, quickly became popular practice Japan. It has gradually spread worldwide, especially Eastern Asia, South Korea China, its excellent clinical outcomes. already become standard Asian countries; however, case volume Western countries still limited. Surprisingly, with benign lesions undergo surgery United States, ratio among surgically treated cases increasing.1Peery A.F. Cools K.S. Strassle P.D. et al.Increasing rates nonmalignant colorectal polyps States.Gastroenterology. 2018; 154: 1352-1360Abstract Full Text PDF PubMed Scopus (63) Google Scholar In neoplasia nearly always removed endoscopically EMR effective technique, large difficult lesions; more complex lengthy procedure than EMR. Owing complexity, prediction procedural time nonexperts difficult. lack experts training systems main reason why widely used countries,2Fuccio L. Hassan C. Ponchon T. al.Clinical outcomes neoplasia: systematic review meta-analysis.Gastrointest Endosc. 2017; 86: 74-86Abstract (102) Scholar, 3Draganov PV, Wang AY, Othman MO, al. AGA Institute update: States. 2019;17:16-25.Google 4McCarty T.R. Aihara H. Current state education dissection: translating strategy success USA.Dig 2020; 32: 851-860Crossref (7) unpredictable procedures reasons situation. important predict difficulties Imai al,5Imai K. Hotta Ito S. al.A risk-prediction model failure or perforation during neoplasms.Dig 932-939Crossref (5) working high-volume center recently established They identified endoscopist experience, tumor location, morphology, endoscope operability, underlying fold, fold convergence (which suggests presence severe fibrosis) significant factors. If be system, we can assign experienced operator procedure. By contrast, Li al6Li B. Shi Q. Xu E.-P. al.Prediction tumors: novel score model.Gastrointest 2021; 94: 133-144.e3Abstract (3) developed another scoring Chinese that probability successful (defined ≤60 minutes) size, circumference lesion, unfavorable anatomic morphology predictors. system grade technical difficulty before Usually, centers, necessary judged impression an expert who familiar countries, factors less available. Therefore, subjectively predictable seems helpful, countries. Additionally, 60 minutes acceptable everywhere world. unexpectedly situations rushing within allocated slots using system. Unfortunately, did include one parameters maneuverability endoscope, crucial factor smooth procedures, probably subjective parameter. Instead, they included locations, generally closely correlated poor endoscope. some adhesion colon long flexible colon, becomes perform regardless tumor. information extremely required. addition, fibrosis predictor study; should challenging situation There causes fibrosis. Large protruding lesions, 0-Isp haustral usually induced movement lesions. Previous multiple biopsies flat major Especially there resulting attempts partial tattooing primary physicians.3Draganov Neoplastic crossing surgical suture line accompany Chronic inflammation, ulcerative colitis, massive under Needless say, burden educate every careless lesion cause serious problems. At same time, everyone aware accurate essential making proper strategy.7Tanaka Kashida Saito Y. al.Japan Gastroenterological Endoscopy Society guidelines dissection/endoscopic mucosal resection.Dig 219-239Crossref (49) common preoperative detailed colonoscopic tertiary referral where planned check characteristics target depth lesion. When suitable fibrosis, direction gravity according patient’s position carefully checked doctor. All developing strategies estimating times other words, impossible make plan without information. uncommon examination makes those For reason, highly recommended secondary center, First, entire magnification narrow-band imaging crystal violet staining ensure resection. Even when doctor taken biopsy specimens, use them sometimes unreliable kind pinpoint diagnosis. specimen peripheral inhomogeneous underestimated. Second, mentioned al,6Li these metrics might able artificial intelligence near future. mandatory ourselves moment obtain Third, judge applicability complicated patient. parameter predicting thought metric intelligence. objective centers planned; results far better centers. institutions would drastically improve if endoscopists could planning treatment. easy good, trainees. bad, good operators. super-experts extended schedules patient may candidate laparoscopic surgery. Under circumstances, issue Gastrointestinal includes useful data high-level institution; directly applicable institutions. To introduce smoothly each interpret his her own skill level. We hope ESD, currently sophisticated treatment, will around world Dr Yahagi paid speaker advisor for, ownership interest, Olympus Co Ltd; interest Pentax Boston Scientific Co; consultant Top Corporation; EA Pharma, Takeda Pharmaceuticals, Otsuka AstraZeneca, Dach-Sajyo recipient research grants Kaigen Pharmaceutical Sanwa Kagaku Kenkyusho Ltd. author disclosed no financial relationships. Prediction modelGastrointestinal EndoscopyVol. 94Issue 1PreviewEndoscopic (ESD) promising removing tumors, aim study establish grading Full-Text