Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

Abstract

ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.

Conflict of interest statement

P. Bhandari provides consultancy to Boston Scientific (2018–2022); his department has received research grants from Olympus UK (2019–2022), Fujifilm Europe (2019–2022), 3-D Matrix (2019–2022), and NEC Japan (2018–2022). M.J. Bourke has received research support from Boston Scientific, Olympus, and Cook Medical (2016 to 2022, ongoing). P.H. Deprez has received lecture fees from Olympus (2010–2021) and Erbe (2010–2020). M. Dinis Ribeiro is Co-Editor-in-Chief of Endoscopy; he has provided consultancy to Medtronic (2021) and Roche (2022); his department has received a research grant (loan) from Fujifilm (2021–2022). A. Lemmers has received consultancy fees from Cook Endoscopy (2021); his department receives a research grant from Boston Scientific (2021–2023). R. Maselli has provided consultancy to Erbe Medical (2018 to present); her department has received consultancy from Fujifilm (2018 to present). O. Pech has received speaker’s honoraria from Medtronic, Boston Scientific, Fujifilm, and Olympus (over 5 years). M. Pioche has provided consultancy and training for Olympus, Pentax, Cook, and Norgine (2017–2022). J.E. van Hooft’s department has received research grants from Cook Medical (2014–2019) and Abbott (2014–2017); she has received lecture fees from Medtronics (2014–2015, 2019), Cook Medical (2019), and Abbvie (2021), and consultancy fees from Boston Scientific (2014–2017) and Olympus (2021). B.L.A.M. Weusten has received financial support for IRB-approved studies from Pentax Medical (2017–2022), and financial research support from Aqua Medical (2020–2022), and has provided consultancy to Pentax Medical (2021–2022). D. Libânio, B.A.J. Bastiaansen, R. Bisschops, G. Esposito, H. Messman, P. Pimentel-Nunes, and M. Vieth have no competing interests.

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