Advanced Endoscopy Fellows Program | September 2024-ESD Guidelines 2023

ESD Guidelines 2023

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The American Society for Gastrointestinal Endoscopy (ASGE) has released guidelines on the use of endoscopic submucosal dissection (ESD) for managing early-stage esophageal and gastric cancers. These guidelines, based on a thorough review using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, compare ESD with endoscopic mucosal resection (EMR) and surgery.<br /><br />### Key Recommendations:<br />1. #### Esophageal Squamous Cell Carcinoma (ESCC):<br />   - **Lesions ≤15 mm**: Either ESD or EMR are acceptable.<br />   - **Lesions >15 mm**: ESD is preferred over EMR due to its higher clinical success and lower recurrence rates. Surgery is discouraged for non-invasive, well-differentiated tumors.<br /><br />2. #### Esophageal Adenocarcinoma (EAC):<br />   - **Lesions ≤20 mm**: Either ESD or EMR can be used.<br />   - **Lesions >20 mm**: ESD is recommended over EMR for better outcomes. <br /><br />3. #### Gastric Adenocarcinoma (GAC):<br />   - **Lesions ≤20 mm**: Either ESD or EMR are appropriate.<br />   - **Lesions 20-30 mm**: ESD is preferred.<br />   - **Lesions >30 mm**: Surgery is generally preferred, especially for poorly differentiated tumors, though EMR/ESD might be an option in select well/moderately differentiated, non-ulcerated, intestinal-type tumors.<br /><br />### Outcomes and Evidence:<br />- **ESD vs. EMR**: ESD offers higher clinical success rates and lower local recurrence for both esophageal and gastric cancers, albeit with increased procedural time and risk for certain adverse events like perforation.<br />- **ESD vs. Surgery**: Surgery demonstrates higher curative success but with increased mortality and infection rates. ESD is less invasive and associated with quicker recovery and fewer immediate postoperative complications, making it a viable option for appropriate early-stage lesions.<br /><br />### Surveillance & Recurrence Management:<br />- For patients with non-invasive cancers treated with ESD or EMR, regular endoscopic surveillance is recommended. The frequency ranges from 3-12 months in the first year and annually thereafter.<br />- For recurrences, options include repeat endoscopic resection, surgery, or systemic therapies based on multidisciplinary review.<br /><br />### Future Directions:<br />The guidelines call for additional robust randomized controlled trials (RCTs) and long-term studies to refine these recommendations further. Emphasis is also placed on training and expertise development to improve the safety and efficacy of ESD.<br /><br />### Practice Implications:<br />While these guidelines provide a structured approach to the management of early esophageal and gastric cancers, clinical decisions should consider individual patient scenarios, local expertise, and the availability of resources. These guidelines aim to standardize care, improve outcomes, and minimize practice variability; however, they are not a substitute for professional medical judgment.<br /><br />### Conclusion:<br />The ASGE supports ESD over EMR for larger and more complex early-stage esophageal and gastric tumors and recommends surgical evaluation for more invasive and poorly differentiated tumors. These guidelines are intended to inform clinical practice and emphasize the need for further research to confirm and refine these recommendations.

Keywords

ASGE guidelines

endoscopic submucosal dissection

early-stage esophageal cancer

early-stage gastric cancer

endoscopic mucosal resection

esophageal squamous cell carcinoma

esophageal adenocarcinoma

gastric adenocarcinoma

clinical success rates

surveillance and recurrence management