Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Technology Insight: endoscopic submucosal dissection of gastrointestinal neoplasms

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 511–520 (2007)Cite this article

Abstract

Gastrointestinal neoplasms can be cured by local resection as long as the lesions are in the early stage and have not metastasized. Endoscopic resection is a minimally invasive treatment for early-stage gastrointestinal neoplasms, and endoscopic submucosal dissection (ESD) is one type of endoscopic resection that has been developed in the past 10 years. For ESD to be a reliable, curative treatment for gastrointestinal neoplasms, it is necessary for the endoscopist to detect the lesion early, make a precise pretreatment diagnosis, ensure that the patient has the correct indication for endoscopic resection, and have the skill to perform ESD. For early lesion detection, endoscopists should pay attention to subtle changes in the surface structure, the color of the mucosa and the visibility of underlying submucosal vessels. Chromoendoscopy and magnifying endoscopy are useful for determining the margin of the lesions for pretreatment diagnosis, and endoscopic ultrasonography and magnifying endoscopy are useful for determining the depth of invasion. For ESD to be successful, local injection of sodium hyaluronate helps maintain mucosal elevation during dissection. Selecting the appropriate knife, using transparent hoods wisely, employing a good strategy that uses gravity, and having good control of bleeding are all needed to make ESD reliable.

Key Points

  • Endoscopic submucosal dissection (ESD) is a recently developed type of endoscopic resection that enables reliable and complete resection of early gastrointestinal neoplasms

  • For ESD to be a reliable, curative treatment for gastrointestinal neoplasms, it is necessary for the endoscopist to detect the lesion early, make a precise pretreatment diagnosis, ensure that the patient has the correct indication for endoscopic resection, and have the skill to perform ESD

  • For early detection of gastrointestinal lesions, endoscopists should pay attention to subtle changes in the surface structure and the color of the mucosa and the visibility of underlying submucosal vessels

  • Chromoendoscopy and magnifying endoscopy can help to determine the margin of the lesions as part of the pretreatment diagnosis

  • Endoscopic ultrasonography and magnifying endoscopy can help to determine the depth of invasion of the lesion

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Subclassification of the esophageal mucosa and submucosal layer
Figure 2: A precutting needle knife (KD-10Q-1, Olympus Corp)
Figure 3: ST hoods help to ensure safe and well-controlled use of a needle knife
Figure 4: Endoscopic submucosal dissection of an early gastric cancer

Similar content being viewed by others

References

  1. Yamamoto H and Kita H (2005) Endoscopic therapy of early gastric cancer. Best Pract Res Clin Gastroenterol 19: 909–926

    Article  Google Scholar 

  2. Gotoda T et al. (2006) Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 41: 929–942

    Article  Google Scholar 

  3. Yamamoto H et al. (2005) Mucosectomy in the colon with endoscopic submucosal dissection. Endoscopy 37: 764–768

    Article  CAS  Google Scholar 

  4. Yamamoto H (2005) Endoscopic submucosal dissection of early cancers and large flat adenomas. Clin Gastroenterol Hepatol 3 (Suppl 1): S74–S76

    Article  Google Scholar 

  5. Oyama T et al. (2005) Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 3 (Suppl 1): S67–S70

    Article  Google Scholar 

  6. Yoshida T et al. (2004) Narrow-band imaging system with magnifying endoscopy for superficial esophageal lesions. Gastrointest Endosc 59: 288–295

    Article  Google Scholar 

  7. Gossner L et al. (2006) Comparison of methylene blue-directed biopsies and four-quadrant biopsies in the detection of high-grade intraepithelial neoplasia and early cancer in Barrett's oesophagus. Dig Liver Dis 38: 724–729

    Article  CAS  Google Scholar 

  8. Endo T et al. (2002) Classification of Barrett's epithelium by magnifying endoscopy. Gastrointest Endosc 55: 641–647

    Article  Google Scholar 

  9. Hoffman A et al. (2006) Acetic acid-guided biopsies after magnifying endoscopy compared with random biopsies in the detection of Barrett's esophagus: a prospective randomized trial with crossover design. Gastrointest Endosc 64: 1–8

    Article  CAS  Google Scholar 

  10. Sharma P et al. (2006) Non-biopsy detection of intestinal metaplasia and dysplasia in Barrett's esophagus: a prospective multicenter study. Endoscopy 38: 1206–1212

    Article  CAS  Google Scholar 

  11. Goda K et al. (2007) Usefulness of magnifying endoscopy with narrow band imaging for the detection of specialized intestinal metaplasia in columnar-lined esophagus and Barrett's adenocarcinoma. Gastrointest Endosc 65: 36–46

    Article  Google Scholar 

  12. Kara MA et al. (2006) Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging. Gastrointest Endosc 64: 155–166

    Article  Google Scholar 

  13. Triantafillidis JK and Cheracakis P (2004) Diagnostic evaluation of patients with early gastric cancer—a literature review. Hepatogastroenterology 51: 618–624

    PubMed  Google Scholar 

  14. Japanese Gastric Cancer Association (1998) Japanese classification of gastric carcinoma—2nd English edition. Gastric Cancer 1: 10–24

  15. [No authors listed] (2003) The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 58 (Suppl): S3–S43

  16. Bond JH (2003) Colon polyps and cancer. Endoscopy 35: 27–35

    Article  CAS  Google Scholar 

  17. Kudo S et al. (1995) The problem of de novo colorectal carcinoma. Eur J Cancer 31A: 1118–1120

    Article  CAS  Google Scholar 

  18. Soetikno R et al. (2006) Nonpolypoid (flat and depressed) colorectal neoplasms. Gastroenterology 130: 566–576

    Article  Google Scholar 

  19. Kudo S et al. (2000) Colonoscopic diagnosis and management of nonpolypoid early colorectal cancer. World J Surg 24: 1081–1090

    Article  CAS  Google Scholar 

  20. Kudo S et al. (2001) Endoscopic mucosal resection of the colon: the Japanese technique. Gastrointest Endosc Clin N Am 11: 519–535

    Article  CAS  Google Scholar 

  21. Sano T et al. (1990) Early gastric cancer: endoscopic diagnosis of depth of invasion. Dig Dis Sci 35: 1340–1344

    Article  CAS  Google Scholar 

  22. Yanai H et al. (1997) Endoscopic ultrasonography and endoscopy for staging depth of invasion in early gastric cancer: a pilot study. Gastrointest Endosc 46: 212–216

    Article  CAS  Google Scholar 

  23. Akahoshi K et al. (1998) Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe. Gastrointest Endosc 48: 470–476

    Article  CAS  Google Scholar 

  24. Yasuda K et al. (2005) Role of endoscopic ultrasonography in the diagnosis of early esophageal carcinoma. Gastrointest Endosc Clin N Am 15: 93–99

    Article  Google Scholar 

  25. Akahoshi K et al. (1991) Preoperative evaluation of gastric cancer by endoscopic ultrasound. Gut 32: 479–482

    Article  CAS  Google Scholar 

  26. Matsumoto Y et al. (2000) Endoscopic ultrasonography for diagnosis of submucosal invasion in early gastric cancer. J Gastroenterol 35: 326–331

    Article  CAS  Google Scholar 

  27. Kashida H and Kudo SE (2006) Early colorectal cancer: concept, diagnosis, and management. Int J Clin Oncol 11: 1–8

    Article  Google Scholar 

  28. Makuuchi H (2001) Endoscopic mucosal resection for mucosal cancer in the esophagus. Gastrointest Endosc Clin N Am 11: 445–458

    Article  CAS  Google Scholar 

  29. Yao K et al. (2002) Novel magnified endoscopic findings of microvascular architecture in intramucosal gastric cancer. Gastrointest Endosc 56: 279–284

    Article  Google Scholar 

  30. Sumiyama K et al. (2004) Combined use of a magnifying endoscope with a narrow band imaging system and a multibending endoscope for en bloc EMR of early stage gastric cancer. Gastrointest Endosc 60: 79–84

    Article  Google Scholar 

  31. Seto Y et al. (1997) Impact of lymph node metastasis on survival with early gastric cancer. World J Surg 21: 186–189

    Article  CAS  Google Scholar 

  32. Kunisaki C et al. (2001) Prognostic factors in early gastric cancer. Hepatogastroenterology 48: 294–298

    CAS  PubMed  Google Scholar 

  33. Eguchi T et al. (2006) Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases. Mod Pathol 19: 475–480

    Article  Google Scholar 

  34. Endo M et al. (2000) Clinicopathologic analysis of lymph node metastasis in surgically resected superficial cancer of the thoracic esophagus. Dis Esophagus 13: 125–129

    Article  CAS  Google Scholar 

  35. Oyama T et al. (2002) Lymph nodal metastasis of m3, sm1 esophageal cancer [Japanese]. Stomach and Intestine 37: 72–74

    Google Scholar 

  36. The Japan Esophageal Society (2002) Guidelines for the treatment of esophageal cancer [Japanese]. [http://www.esophagus.jp/pdf_files/esophagus200212.pdf] (accessed 10 July 2007)

  37. Takubo K et al. (1991) Double muscularis mucosae in Barrett's esophagus. Hum Pathol 22: 1158–1161

    Article  CAS  Google Scholar 

  38. Vieth M and Stolte M (2005) Pathology of early upper GI cancers. Best Pract Res Clin Gastroenterol 19: 857–869

    Article  Google Scholar 

  39. Stein HJ et al. (2005) Surgery for early stage esophageal adenocarcinoma. J Surg Oncol 92: 210–217

    Article  CAS  Google Scholar 

  40. Holscher AH et al. (1997) Early adenocarcinoma in Barrett's oesophagus. Br J Surg 84: 1470–1473

    Article  CAS  Google Scholar 

  41. Stein HJ et al. (2005) Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection. Ann Surg 242: 566–573

    PubMed  PubMed Central  Google Scholar 

  42. Nigro JJ et al. (1999) Occult esophageal adenocarcinoma: extent of disease and implications for effective therapy. Ann Surg 230: 433–438

    Article  CAS  Google Scholar 

  43. Buskens CJ et al. (2004) Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features. Gastrointest Endosc 60: 703–710

    Article  Google Scholar 

  44. Westerterp M et al. (2005) Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction. Virchows Arch 446: 497–504

    Article  Google Scholar 

  45. Ell C et al. (2007) Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer) Gastrointest Endosc 65: 3–10

    Article  Google Scholar 

  46. Adachi Y et al. (2002) Modern treatment of early gastric cancer: review of the Japanese experience. Dig Surg 19: 333–339

    Article  Google Scholar 

  47. Japanese Gastric Cancer Association (2001) Guidelines for the Treatment of Gastric Cancer. Tokyo: Kanehara & Co., Ltd

  48. Sano T et al. (1992) Lymph node metastasis from early gastric cancer: endoscopic resection of tumour. Br J Surg 79: 241–244

    Article  CAS  Google Scholar 

  49. Yamao T et al. (1996) Risk factors for lymph node metastasis from intramucosal gastric carcinoma. Cancer 77: 602–606

    Article  CAS  Google Scholar 

  50. Namieno T et al. (1998) Assessing the suitability of gastric carcinoma for limited resection: endoscopic prediction of lymph node metastases. World J Surg 22: 859–864

    Article  CAS  Google Scholar 

  51. Ono H et al. (2001) Endoscopic mucosal resection for treatment of early gastric cancer. Gut 48: 225–229

    Article  CAS  Google Scholar 

  52. Matsushita M et al. (1997) Endoscopic mucosal resection of gastric tumors located in the lesser curvature of the upper third of the stomach. Gastrointest Endosc 45: 512–515

    Article  CAS  Google Scholar 

  53. Yamamoto H et al. (2002) Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate. Gastrointest Endosc 56: 507–512

    Article  Google Scholar 

  54. Yamamoto H et al. (2003) Successful en bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 35: 690–694

    Article  CAS  Google Scholar 

  55. Yamamoto H et al. (2001) Successful en bloc resection of a large superficial gastric cancer by using sodium hyaluronate and electrocautery incision forceps. Gastrointest Endosc 54: 629–632

    Article  CAS  Google Scholar 

  56. Oyama T and Kikuchi Y (2002) Aggressive endoscopic mucosal resection in the upper GI tract—hook knife method. Minim Invasive Ther Allied Technol 11: 291–295

    Article  CAS  Google Scholar 

  57. Yahagi N et al. (2004) Endoscopic submucosal dissection for the reliable en bloc resection of colorectal mucosal tumors. Dig Endosc 16: S89–S92

    Article  Google Scholar 

  58. Rembacken BJ et al. (2001) Endoscopic mucosal resection. Endoscopy 33: 709–718

    Article  CAS  Google Scholar 

  59. Borie F et al. (2004) French Association for Surgical Research. Prognostic factors for early gastric cancer in France: Cox regression analysis of 332 cases. World J Surg 28: 686–691

    PubMed  Google Scholar 

  60. Pelz J et al. (2004) Determination of nodal status and treatment in early gastric cancer. Eur J Surg Oncol 30: 935–941

    Article  CAS  Google Scholar 

  61. Endo K et al. (2005) Evaluation of endoscopic mucosal resection and nodal micrometastasis in pN0 submucosal gastric cancer. Oncol Rep 13: 1059–1063

    PubMed  Google Scholar 

  62. Hanazaki K et al. (1997) Surgical outcome in early gastric cancer with lymph node metastasis. Hepatogastroenterology 44: 907–911

    CAS  PubMed  Google Scholar 

  63. Gotoda T et al. (2000) Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 3: 219–225

    Article  Google Scholar 

  64. Saito Y et al. (2001) Endoscopic treatment for laterally spreading tumors in the colon. Endoscopy 33: 682–686

    Article  CAS  Google Scholar 

  65. Yamamoto H et al. (2004) Endoscopic submucosal dissection using sodium hyaluronate for large superficial tumors in the colon. Digestive Endoscopy 16: 178–181

    Article  Google Scholar 

  66. The Japanese Society for Cancer of the Colon and Rectum (2005) Guidelines for the treatment of colorectal carcinoma [Japanese]. [http://www.jsccr.jp/guideline.html] (accessed 10 July 2007)

  67. Egashira Y et al. (2004) Analysis of pathological risk factors for lymph node metastasis of submucosal invasive colon cancer. Mod Pathol 17: 503–511

    Article  CAS  Google Scholar 

  68. Yamamoto H et al. (1999) A novel method of endoscopic mucosal resection using sodium hyaluronate. Gastrointest Endosc 50: 251–256

    Article  CAS  Google Scholar 

  69. Yamamoto H et al. (1999) A successful single-step endoscopic resection of a 40 millimeter flat-elevated tumor in the rectum: endoscopic mucosal resection using sodium hyaluronate. Gastrointest Endosc 50: 701–704

    Article  CAS  Google Scholar 

  70. Fujishiro M et al. (2005) Tissue damage of different submucosal injection solutions for EMR. Gastrointest Endosc 62: 933–942

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. H Yamamoto is Chief of the Department of International Research and Education for Endoscopy, Jichi Medical University, Tochigi, Japan.,

    Hironori Yamamoto

Authors
  1. Hironori Yamamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hironori Yamamoto.

Ethics declarations

Competing interests

The author is a speaker and consultant for Fujinon Corporation, and holds a patent entitled “Method of endoscopic mucosal resection using mucopolysacharide and local injection preparation” (US Patent number 6,319,260) in conjunction with Fujinon and Seikagaku.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Yamamoto, H. Technology Insight: endoscopic submucosal dissection of gastrointestinal neoplasms. Nat Rev Gastroenterol Hepatol 4, 511–520 (2007). https://doi.org/10.1038/ncpgasthep0906

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpgasthep0906

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing