Endoscopic submucosal dissection: Challenges, innovations, and the road ahead

Table 1 Suggested indications for endoscopic submucosal dissection by the European Society of Gastrointestinal Endoscopy

Organ		Indications for ESD
Esophagus	Squamous cell carcinoma	HGD to well (G1) to moderately (G2) differentiated; Paris 0-II lesions; Absolute indications: M1-m2 involvement with 2/3 or less of the esophageal circumference; Expanded indications: M3 or sm
	Barrett’s esophagus	HGD to moderately (G1 or G2) differentiated T1a (m1-m3) lesions 15 mm (not amenable to en bloc resection by EMR); Patients with Barrett’s esophagus and the following features: Large or bulky area of nodularity; equivocal preprocedural histology; intramucosal carcinoma; suspected superficial submucosal invasion; recurrent dysplasia; and EMR specimen showing invasive carcinoma with positive margins
Stomach		Mucosal adenocarcinoma (and lesions with HGD), intestinal type, G1 or G2 differentiation, size < or 2 cm, no ulceration. Expanded indications: Adenocarcinoma, intestinal type, G1 or G2 differentiation, any size, without ulceration; adenocarcinoma, intestinal type, G1 or G2 differentiation, sm-invasive (< 500 μm); adenocarcinoma, intestinal type, G1 or G2 differentiation, 3 cm, with ulceration; and adenocarcinoma, diffuse type, G3 or G4 differentiation, size 2 cm, without ulceration
Colon and rectum		En bloc resection for lesions at risk for submucosally invasive cancer: Type V Kudo pit pattern, depressed component (Paris 0-IIc), complex morphology (0-Is or 0-IIaþIs), rectosigmoid location: Nongranular LST (adenomas), 20 mm in size granular LST (adenomas), 30 mm in size; Residual or recurrent colorectal adenomas

Endoscopic mucosal resection as first option for: Superficial lesion in Barrett esophagus; gastric (small lesion) < 10 mm, IIa, difficult for endoscopic submucosal dissection; duodenum colorectal nongranular/nondepressed < 20 mm or granular. ESD: Endoscopic submucosal dissection; LST: Laterally spreading tumor; HGD: High-grade dysplasia; EMR: Endoscopic mucosal resection; sm: Submucosal.