Faculty Bibliography

Background: Endoscopic submucosal dissection (ESD) is a technique that allows for the en-bloc resection of large specimens and superficial gastrointestinal tumors thereby providing increased histological diagnosis and lower recurrence rates. However, ESD is challenging and while its application has rapidly spread as a therapeutic option, there is only limited data on the current practice and early experience of the United States. Aims: To evaluate the development of ESD in the United States by assessing the current practice and short-term outcomes of upper and lower ESD for the treatment of superficial gastrointestinal lesions. Methods: In a retrospective, multi-center study, we reviewed cases in which upper and lower ESD was used to treat superficial gastrointestinal lesions. ESD was completed in six institutions by 7 different endoscopists. Retrospective review of all cases was completed to obtain size and location of the lesion, pre-procedure indication, procedure time, instruments used, submucosal injection solutions, complications (e.g. bleeding, perforation) and follow up information when available. Results: A total of 304 ESD procedures were completed from the 6 centers. The mean case volume per center was 51 (range 11 - 84). The lesions treated by ESD were located in the stomach (n = 121), esophagus (n = 75), duodenum (n = 8), cecum (n = 6), right colon (n = 12), transverse colon (n = 7), sigmoid colon (n = 17), and rectum (n = 58). The mean lesion size was 38 mm (SD +/- 22.4 mm, range 6 - 150 mm). The indication for ESD resection was carcinoma in 30%, dysplasia in 59.2%, and benign lesions in 11%. En bloc resection was achieved in 78.0% of cases, with complete R0 resection in 56.3% of which 83 (27.3%) had positive margins (36 deep and 47 lateral) and 32 (10.5%) had lymphovascular or neural invasion. The median ESD procedure time was 120 minutes (range 25 - 600 minutes). The most frequent instruments used included the dual knife (33.0%) and IT knife (32.8%) with a combination of knives used in 51% of cases (mean 1.6 knives, +/- 0.7, range 1 - 4). APC was used in 16.5% of cases and preventative hemostasis was attempted in 86.2% of cases. Short-term morbidity was 14.1% included 13 cases of perforation (4.3%) and 30 hemorrhages (9.9%). With available follow up data, 31 patients (10.3%) subsequently had surgery and of these, 9 (29%) had disease in the surgical specimen. Of 146 patients (48%) who had a follow up endoscopy, 17 (11.6%) had residual disease. Conclusion: ESD is rapidly emerging as a popular technique in the United States to remove superficial gastrointestinal lesions. These findings confirm that ESD is technically feasible and safe. The challenging technique, steep learning curve, and need for optimal lesion selection highlight the need for significant practice in order achieve curative resection

Many devices and techniques have been developed to assist in cases of difficult biliary cannulation. Guidewire-assisted cannulation has become the first-line technique for biliary cannulation. Precut sphincterotomy can be safe and effective if used soon after encountering difficulty. Pancreatic duct stents are an important adjunct to reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult access. Ultimately, cannulation success of greater than 95% and complication rates of less than 5% is the standard that endoscopists doing ERCP should achieve.