So this lecture is slightly dull. So I'm very sorry that this would be too much knowledge and a lot of Names and things but before we go into the indications I'm just talking about concentrate consideration before starting ESD and On why I'm saying that why this is important in term of indication because at the beginning You don't want to do every indication for ESD certain indication are harder than other So realizing what you start with is very important. We don't have yet Recommendation from the US, but we have an ESG recommendation about unsupervised ESD Especially in the colon you really have to follow a curriculum and you want to start lesion limited To three centimeter or less in the antrum or rectum for the first 20 procedures And this sound a little bit too much, but this how they do it in Europe In the first few cases if you are unsupervised if you are in your own in your own hospital You don't have somebody to help you with the cases Maybe it is wise not to say I'm gonna start ESD and then in two three month You're gonna have a robust practice It might take you two to three years till you become confident and that's very important and we're going to talk about learning curve To understand why this is very important So independent factor for procedure success in the hand of expert endoscopist Who did not have a ESD training which by the way most of the people in this room Except few like Felgy is rectal lesions lack of submucosal fibrosis performance of over 100 ESD and lesion is smaller than 35 millimeter So these are the lesion that people are tend to be successful every time they do it later on People refer to you more complex cases and then you're gonna look at competency and doing anything anywhere Successfully and we're gonna look how long it takes you to do that So remember these numbers here rectal no fibrosis Once you do a hundred case will be very good and lesion is smaller than three millimeter so they have a learning curve and this also European guidelines and the envision that you already be doing EMR and They envision that you're gonna set up your unit in a way that you can do the procedure like you have carbon dioxide insufflation You have adequate time in your schedule You cannot do this case and ESD starting at 4 o'clock to finish 8 or 9 or 10 p.m You don't want to do that Also, you're gonna do preparatory training the face you guys in right now at the preparatory training You want to do ex vivo then in vivo and then maybe proctorship then you start doing some clinical ESDs And even when you do your ESDs, you are in phases your first 40 to 50 cases You are still testing the water. You're doing easier lesion. This is a three centimeter rectal antrum Sometime maybe esophageal and then once you get to 80 now We become scaled and now you have to start looking at your quality data You want to know your M block R0 resection curative resection rate? And if you don't know what's your M block resection rate and R0 resection rate Then maybe you are not doing a good job because you have to know what's your data in my center We have a report card for ESD every month and I and it's actually Available for everyone So I know my partners are zero section rate and M block and they know mine and that will help you to think twice before You know, I'm trying to do a case that you'll not be able to do it. So having this transparency is very important So this paper was published in CGH by Stavros Grube and Stavros looked at his speed in the procedure and how long would take him to do three by three centimeter lesion in one hour or less and he'd looked at this nine centimeters square per hour and he Concluded that it took him 250 to 300 cases to reach that level when this paper came There was a lot of I would say controversy about it. This is big number So I I was invited at a fifth reviewer in the study two people said reject people who said accept and It said accept and the editor called me and said, can you please make a decision in this? We have two on two and then I said accept to you know, like surgery and it got published and was very important data So I tried to replicate the same thing but with another idea How how can you consistently no matter what lesion you get in the LEM right side of the cool and anywhere You can get 90% and block resection rate Like if you know that provider he is so good an ESD that no matter what you send him who will do it and it takes in my case is 268 to have a reliable 90% and block resection rate and I also this was published this year and I got many angry comments people saying by publishing this You're making it impossible for people to do ESD, but this is not true This was about when you become very competent ESD that you'll always be successful But that's why you need to know the indication you need to start the easy indication before you go to the next level So I hope right now we understand why? Indications are important and which lesion to start with so now we're going to talk about I Should say this politically correct But your testosterone goes higher after a certain number of procedure to take more and more complex cases in your on block resection should go down Yes, which is what's happening on this happen was time. Yeah, it will go down So theoretically you're much more likely to have on block early when you do the three by threes then when you do the five by But once you get to a level you will be always in a good level But then it goes down and then it goes up again. So consistently towards retirement. Yeah And that's when you know and that's when indications comes right because sometime we push the boundaries So we know that we should not push the boundaries So when you push it and when you don't push it and when you will have complication and understand what to do and not to So this is factor for indication is exactly we're talking about what can you do feasible that is possible and you cannot start 25 Centimeter lesion, for example, it will be impossible But there is another factor that's even much more complex, which is related to the indication, which is the lymph node metastasis So if we look at this slide here lymph nodes is outside the GI tract But the lymph nodes send lymphatic capillary into the GI tract and this lymphatic capillaries are very rich in the muscle layers But they do reach the submucosa and as you can see here in very rare occasion They can be in the mucosa. So there are reports of mucosal cancer that have lymph node metastasis So you can remove a lesion like this here and it is very limited to the mucosa and there is no risk of lymph node Metastasis or you can it can be here in the submucosa and maybe it did not get to the lymph node or maybe it got to the lymph node and Sometime your pathologist would be able to see that and pathology and it says there is lymphovascular invasion and sometime They may not be able to do it so You can bring a patient and you can remove the lesion with R0 resection rate, which mean like no residual lesions but yet this patient need to go for surgery because you can see that the lesion is going to the lymph node and it's Very hard to explain to the patient. Yes, we had an R0 resection, but this resection is not Curative so understanding the difference between both is very important and all the indication of ESD is around When you stop ESD because ESD would be associated as lymph node metastasis I'm gonna give you an extreme story and this story should not scare you so much but it does happen. I had a patient refer to me for rectal cancer rectal polyp and I removed the polyp and it was read by pathology as T1 tumor Early superficial invasion of the submucosa. No LVI So anytime you have cancer I treat it as cancer send them to oncology Do like I never tell them it is 100% cure rate I told them we have to follow you up three months later. They have a CT scan It was normal another three months later. They have a PET scan and something light up in the liver They had a liver mets from early superficial rectal cancer. That's by the way very uncommon and there are certain patient have certain genetic traits that Makes LVI is higher In fact, there's more data now showing that submucosal cancer or cancer in the t1 cancer Can be treated endoscopically, but you have to think about these extreme cases when you do the procedures So now we start about one by one I have only two minutes to cover this but now we understand that when ESD started it started in this green spot gastric lesion So started in Japan for a need for screening for gastric cancer and gastric cancer were removed by surgery But there were too many surgeries and then there was EMR and by 2001 they decided to remove smaller lesion or early cancer non-ulcerated differentiated tumor by ESD So that is the grandfather of ESD indication gastric cancer Limited to the mucosa and differentiated then later on they start to expand the criteria So what about doing up to 3 centimeter? So what if the lesion have an ulcer but the ulcer the lesion itself is not large So this was all expanded criteria and then later on what about of the tumor in the submucosa? This was like SM1 then later on undifferentiated too So I did this meta-analysis in 2018 looking at all these what we call expanded criteria So we have absolute which is the green box and the expanded and we can see here The risk of lymph node metastasis is less than 1% is negligible So data was accumulating people was publishing that the undifferentiated and submucosal are the main problem and based on a lot of data including this study the Guidelines change in Japan for early cancer and they came up with this more sophisticated guidelines Everything in black here becoming absolute now So now any differentiated tumor less or more than 2 centimeter any differentiated tumor can be removed by ESD Any undifferentiated as long as it is less than 2 centimeter. This was before that expanded criteria Now it is absolute criteria and any ulcerated lesion less than 3 centimeter and the other will be relative indications again, I have to warn you about Risk of lymph node metastasis and submucosal lesion anything going to submucosa There is always risk of lymph node metastasis. Even if you decide not to send the patient for surgery try to entertain adjuvant chemotherapy or Closed surveillance because this patient no matter how you think they are safe. They may not be safe So that's would be the take-home message for these patients So then in United States, we were lucky that we finally had Guidelines for gastric cancer and these guidelines in any country are limited by availability of The people who are doing it and and and dr. Dragunov Peter and I were in this guidelines That was not easy because we could not say ESD indication as we had to come up with this wording We suggest ESD over EMR so any well differentiated early gastric cancer Measuring under 2 centimeter since it's less than 2 centimeter. You can take it with snare We did not make any recommendation against or for EMR ESD but if it is larger than 2 centimeter or 2 to 3 we suggested ESD over EMR and For patient was well and well well differentiated early gastric cancer We recommend again a surgery but any patient was poorly differentiated tumor We suggest surgical evaluation as you can see here. This is what I call skeleton recommendations and Unfortunately, I know it seems like it's a skeleton recommendation, but for the practitioner in United States The this for them is very complicated It will be very hard for them to follow or understand and I'm not only that we do not have a screening HD Program to apply any of these criteria So I consider this by itself that at least in United States The ASGE now have a guidelines for gastric cancer is a win. This was the first step This is an example of a tubular adenoma of the stomach that would be removed by ESD. Now we'll switch gear to esophageal ESD. So Japanese has started for esophageal ESD criteria and I have to tell you now that in Japan and most of Japanese data will be related to squamous cell carcinoma because they don't see a lot of adenocarcinoma. In United States we do both but mostly adenocarcinoma more than squamous. So this guidelines which were written in 2018 was based on squamous cell carcinoma. So it's non-invasive carcinoma in situ, intramucosal invasive limited to the lamina propria which is M2 without visual infiltration, no lymph node metastases and you can read it here less than two-third of the circumference because there is a strong belief that more than two-third of the circumference will cause stricture. So initially the indication was saying do not do this lesion and there was relative indication here any lesion deeper than 200 micromillimeter in the submucosa that's called SM1 lesions and this by itself another story or anything that has risk of lymph node metastases and anything above 10 you should not do it. So if we take a look here 2020 there was more updated guidelines and the guidelines now realize that you can actually do circumferential ESD with no problem but the problem when you do circumferential ESD the structure if it's shorter structure you can either inject steroid and do dilation. If it's a very long structure you're going to be in big trouble and you can say you with a stent no stent to the moment you remove the stent it will close up again so the guidelines now start differentiated between non-circumferential and whole circumference as non-circumferential you can go for endoscopic resection if it is a whole circumference size becoming important now lesions less than five centimeter you can still do endoscopic resection more than five centimeter you should consider surgery or chemoradiation and that's for T1H tumor limited to the lamina or epithelium if the tumor is deeper which is the SM1 or M3 this is T1B SM1 if it is non-circumferential you can still do endoscopic resection but there is something very important you have to assist for curability whenever you remove any lesion in submucosa what would be the most important thing to look for you guys can tell me now when you remove the lesion from the submucosa so margins and what in addition to margins LVI right so now you are looking for LVI and now you are looking for perineural invasion and now you're looking for criterias other criteria like differentiation to see what you're going to do with the tumor that's called the curative curability assessment if it is deep tumor involving all the circumference you want to go for surgical resection that's how hard it is to treat squamous cell carcinoma and luckily we don't treat a lot of them and why i think they are hard you can see here was local iodine that's one cancer this another spot there is another spot is always have like satellite lesion next to the main lesion so you end up resecting large area in the lumen when you do squamous cell carcinoma so that's showing the different literature published on esophageal and gastric cancer showing the lymph node metastasis which can go up to 25 so you have to be careful with that all right going back to the ASG guidelines when it came to the esophagus it was slightly heated when we are talking about size and which lesion you remove by EMR versus ESD and we suggested ESD over EMR for squamous dysplasia or early stage cancers that's non-ulcerated well differentiated no submucosa invasion but measuring 15 millimeter understanding that squamous cell carcinoma will have satellite lesion so even if it's small you would like to do a ESD in this situation if it is smaller than 15 millimeter we said that's fine you can do EMR but we recommended again a surgery again for well differentiated tumor when it came to barrett esophagus and nodule a lot of our doctors are so good at removing them with EMR so you cannot make a guidelines using this 15 millimeter and say anything above 15 do ESD so that's when i think peter and others suggested two millimeter he and i had dad you remember this discussion you came up with a two millimeter at that time right 20 millimeter yeah so the two millimeter 20 some people felt that you can remove on block up to 220 millimeters with EMR techniques which in my mind is very borderline sometimes you do sometimes you don't because you're basically suctioning and you hope for the best i still think that the 15 millimeter is a better cut off but question for you peter yes so if you have somebody with barrett's and esophageal cancer let's say the visible portion only looks like 12 millimeters yeah in your practice would you with ESD being so safe and quick to do in the esophagus would you just take it out with ESD making sure you completely removed it and got negative margins or would you EMR that i will answer your question by telling you a story okay i was involved into a debate and the debate was ESD versus EMR for barrett's esophagus and the original invitation letter it was not clear which side of the debate and i was horrified when i learned that i'm on the EMR side i said guys you must be kidding me i have not done EMR esophagus for god knows how many years but it was a good exercise so besides size there are other things bulk the bulky delusion the more likely ESD will be a benefit depression vascular pattern and finally what the pre-procedure histology says if it is intramucosal cancer or above i definitely go ESD without any question and lastly has the lesion been previously treated and that's what the most recent guidelines saying if it is post RFA or post EMR recurrence ESD is the way to go there is one category now we have three guidelines the ASG guidelines the ACG guidelines and the AGA guidelines which came just a couple of months ago on barrett's and they basically say pretty much the same what i just stated one thing that they don't cover is a clinical situation that we see all the time you get a biopsy of a lesion says at least intramucosal cancer and of course the pathology is hedging because they just get mucosa they cannot tell you whether there is invasive component i clearly go for ESD there so to answer your question i do ESD in the vast majority of cases why because i can and as you correctly pointed out it's actually once you get the hang of it it's not that long of a procedure even for smaller lesions but we this is guideline i mean you have to look at the literature and the literature on barrett's and ESD is a bunch of case series basically there is a single randomized control study which is 20 patients in each arm that was done more than 10 years ago and very little relevance in 2024 so we need more data yeah and actually the guidelines too did not say recommend EMR over ESD say we do not need a recommendation for or again it's either ESD or EMR basically we leave it for if it's smaller than two centimeters all right so now actually now we're going to go to chronic ESD so this uh this was very nice um publication called multi-society task force published in 2020 and tonya uh cultenbach and other doug ricks were in this paper and they were basically talking about how can you assist lesions and you can see here for all of you in the audience just learn this lesion here that has a depressed and heaped up margin these are ulcerated extubated this is cancer you don't want to do ESD for this lesion just remember that that's not an ESD indication and i drew this myself to show the difference between real depressed lesion and actually elevated lesion with slight depression because sometimes people say depressed lesion is not really depressed because because around it is normal you really want to see that the ulcer is going deep and it become like have a heaped up mucosa so you see the mucosa around it raised like you see here once you have an ulcer everything around it will be buckered and raised like that versus when you have a slight depression and an elevated lesion and this called 2a slash 2c the other one is 2c slash 2a and the difference between them and then we know here for paris classification this ulcerated lesion that we just show have a 61 percent risk of lvi so you don't want to do remove these lesions now there's another classification granular versus non-granular lst so there's a and b this is granular and this is also a granular number c here is non-granular and that's a ulcerated one and you can see a risk of submucosa invasion is 3.2 percent in the granular 15 and non-granular and max around 10 so that's why esd has to be done for all these lesion that are flat so granular versus non-granular if you have a large nodule too you want to remove it by itself even if you're doing emr so that's something you should consider and remember here anything going beyond sm1 in the colon will have a risk up to 10 which is a cutoff for removal so you can conclude that you don't want to do anything beyond sm1 which is 1000 micrometer in the colon what are predictor of lymph node metastases this you'll know them not before you remove the lesion it's after you remove the lesion if you find it's deeper than 1900 venus invasion poor differentiation mucinous adenocarcinoma or tumor budding if you read in your report any of the thing you should send the patient for surgery so back to the u.s multi-task force when it came when you suspect submucosa invasion and they say it is minimal risk they said here emr esd if complete resection is feasible and safe so again the same wishy-washy recommendation in the united states but i know that we're going to have a esd recommendation for colonic indication very soon and i think swan is working on one i don't know if she's gonna tell us anything about what she's doing in there but i hope it will have some clear indications you want to comment in this and no consensus yet because uh the emr experts uh feel that if we recommend a non-granular uh lst even flat elevated type for esd then no one can really take care of patients so still controversy about indication particularly in the colon oh right i think a lot of the apprehension with guidelines is once you recommend something more than the other in a small expert group you're forcing everyone else in the world like someone was telling me one of my former fellows that in the state of oklahoma there's only one person with a third space or something like that so it's very hard now you you're making availability of care and in some other older technique that worked for so many years yeah becomes questionable and i think this is where that apprehension is so that's here quickly that's a lesion granular letter spreading was one large nodule this one should be removed by esd and the diagnosis here tubular villus adenomas high-grade dysplasia this another one non-granular bulky as you can see here diagnosis is well differentiated adenocarcinoma and you can see it is the depth of invasion is minimal but that's how much submucosa i get by esd and i will stop here so that somebody else can give their talk thank you so much

Endoscopic Submucosal Dissection

ESD training

lesion removal

gastric and esophageal cancers

European guidelines

squamous cell carcinoma