Endoscopic Submucosal Dissection ESD

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1 Endoscopic Submucosal Dissection ESD Peter Draganov MD Professor of Medicine Division of Gastroenterology, Hepatology and Nutrition University of Florida

2 Gastrointestinal Cancer Lesion that Can be Treated by Endoscopy High grade dysplasia/early cancer confined to the mucosa or superficial submucosa No lymph node metastasis

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4 The Traditional Approach

5 Colonic EMR Prospective in 479 pts: complete resection 89% Complications 8% bleeding 3% perforation 1.3% (3 pts treated w/endoscopy, 3 with surgery) Recurrence 20.4% Moss A. Gastroenterology. 2011;140(7):1909

6 Colonic EMR Retrospective cohort 315 defiant polyps Mean size 23 mm Compete eradication 91% (APC 24%) Complications 12% Recurrence 27% Buchner AM. GIE ;76(2):255

7 Colonic EMR Prospective cohort 252 large (> 20 mm) sessile polyps completely resected Residual/Recurrent adenoma at F/U 40% Knabe M. Am J Gastroenterol 2014;109;183

8 Colonic EMR Relatively easy with short procedure duration Successful and safe in most cases But!!! No standardized technique Requires expertise Complete resection not possible in all cases (difficult access, fibrosis, recurrent lesion, tattoo at the base) Adjunctive therapy frequently needed (APC) Major complications are rare but possible Fragmented specimen High recurrence rate (20% to 40%)

9 What is ESD? Developed in Japan to treat early gastric cancer

10 Why ESD?

11 Why ESD? En-bloc resection regardless of size Lower recurrence rate/higher curative rate Allows resection when EMR is not feasible Accurate histopathologic assessment of curative treatment Preserves organ integrity with higher quality of life

12 ESD Has Lower Recurrence and Higher Curative Rate Compare with EMR

13 ESD Has Lower Recurrence and Higher Curative Rate Compare with EMR TP0429V01 Cao Y et al. Endoscopy, 2009

14 ESD Allows Accurate Histopathologic Assessment One piece is better than piecemeal

15 ESD Preserves Organ Integrity and Patient Quality of Life Open

16 ESD Preserves Organ Integrity and Patient Quality of Life Open Laparoscopic

17 ESD Preserves Organ Integrity and Patient Quality of Life Open Laparoscopic ESD

18 ESD Preserves Organ Integrity and Patient Quality of Life Barrett s s/p RFA with intramucosal Ca

19 Japan has simple solutions to complex problems

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22 Could ESD be another great Japanese invention that the West has overlooked?

23 Why Not ESD in the West? The Early European Experience 188 patients 16 centers 6 cases per center (median) 26 mm median lesion size 71% en-bloc resection 18% perforation Farhat S. Endoscopy 2011;43:664

24 Why Not ESD? It has very limited application in the West It takes a long time to perform It has high complications rate Requires extensive training

25 ESD Has Limited Application in the West?

26 ESD Has Limited Application in the West?

27 ESD Has Limited Application in the West?

28 ESD Allows Resection When EMR is not Feasible s/p Prior EMR

29 ESD Has Limited Applications in the West Large LST Extending to the Dentate Line

30 ESD Preserves Organ Integrity and Patient Quality of Life 10 cm long Barrett s with intramucosal Ca No visible abnormalities

31 ESD Has High Complication Rate Gastric Perforation During 2460 ESDs 121 patients (4.9%) with perforation 4 surgical treatment ( ) 117 endoscopic closure ( ) 2 failure & additional surgical treatment 115 success (98.3%) Minami S, Gotoda T, et al. Gastrointest Endosc, 2006 Ikehara H, Gotoda T, et al. Br J Surg, 2007

32 ESD Requires Extensive Training Visit to Japan to observe experts Can you learn by observing? 38 ESDs in animal model (29 pre-, 9 post-observation). The removal times post-observation were significantly shorter than those pre-observation (32.7±15.0 min vs. 63.5±9.8 min, p<0.001) Draganov PV. World J Gastroenterol. 2014;20:4675

33 You Can Teach an Old Dog New Tricks?

34 ESD Requires Extensive Training Self study Animal work Attend courses More animal work Observation of experts in action Start with easier cases More observation of experts in action The process is very challenging!!!

35 Living in Japan can be challenging

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38 Living in Japan is great

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40 ESD at the University of Florida 94 patients (24F; 70M) Lesion location: 53 Esophagus (57%) 14 Stomach (15%) 2 Duodenum (2%) 5 Colon (5%) 20 Rectum (22%) En-bloc resection rate: 93.6% Median procedure duration: 91.5 min Complications: Perforation - 8 patients (2 treated surgically, 6 treated with endoscopy) Bleeding - 4 patients (treated endoscopically, no transfusions needed) Stenosis 10 patients (treated endoscopically) Mortality related to the procedure: 0%

41 All introduced in Japan! Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc, 1993 EMR-L; Akiyama et al., Gastrointest Endosc, s 1980s 1990s 2000s Polypectomy; Shinya H (colon) ESD; Ono H, Gotoda T et al. Gut, 2001

42 Living in Japan can be funny

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46 Where do we Stand with ESD in the West?

47 Conclusions ESD disadvantages can be overcome Better training Better devices Coordinated effort between Endoscopy societies and industry

48 Conclusions ESD has some clear advantages Higher curative resection rate Less recurrence Accurate pathology evaluation Preserves quality of life

49 The time is now!