Efficacy and safety of pocket-creation method for early gastric cancers

Exploring different techniques for endoscopic submucosal dissection of gastrointestinal lesions: a review of the literature

INTRODUCTION

Endoscopic submucosal dissection (ESD) has revolutionized the management of early gastrointestinal (GI) neoplasms by enabling en bloc resection with high R0 rates. Several modifications of conventional ESD (C-ESD) have been introduced, including pocket-creation (PCM-ESD), tunnel (T-ESD), traction-assisted (TA-ESD), and saline immersion therapeutic endoscopy (SITE-ESD) methods.

AREAS COVERED

A comprehensive literature search was conducted across main databases through February 2025 using keywords related to ESD, with studies selected based on their relevance. While no single technique has demonstrated superior efficacy and safety across different GI regions, a tailored and integrative approach to different techniques could enhance effectiveness. PCM-ESD and T-ESD are particularly advantageous circumferential lesions in the esophagus and rectum, whereas TA-ESD significantly reduces procedure time, particularly in colonic lesions. Moreover, PCM-ESD has demonstrated higher effectiveness for colorectal lesions compared to C-ESD. SITE-ESD has shown benefits in colorectal resections by improving trimming, submucosal space visualization and coagulation control.Advanced traction systems and resection tools has optimized ESD performance. However, selecting the most appropriate approach requires careful consideration of lesion characteristics (particularly fibrosis and location).

EXPERT OPINION

While conventional ESD remains the foundation, TA and SITE are expected to become the preferred approach in select GI regions during the following years.

Tunneled or pocket creation method versus conventional endoscopic submucosal dissection for gastric lesions: a systematic review and meta-analysis

BACKGROUND AND AIMS

Tunneled endoscopic submucosal dissection (T-ESD) and pocket creation-method ESD (PCM-ESD) are considered to have technical advantages over conventional ESD (C-ESD). However, data comparing these techniques for ESD of gastric lesions are limited.

METHODS

PubMed and Cochrane databases were reviewed for relevant studies from their inceptions to October 31, 2023. Studies comparing T-ESD or PCM-ESD (T/PCM-ESD) with C-ESD for gastric lesions were included. The primary outcomes were dissection speed and en-bloc resection. Secondary outcomes were R0 resection, recurrence, perforation, and post-ESD bleeding. A random effects meta-analysis was conducted.

RESULTS

Eight observational studies (359 patients with T/PCM-ESD, 670 patients with C-ESD) were included. T/PCM-ESD was associated with a significantly faster dissection speed (mean difference, 4.42 mm2/min; 95% confidence interval [CI], 2.05-6.79; I2 = 79%). There were no significant differences between the groups in terms of en-bloc resection (risk ratio [RR], 1.01; 95% CI, 1.00-1.03; I2 = 0%), R0 resection (RR, 1.03; 95% CI, 0.99-1.07; I2 = 0%), and recurrence (RR, 0.73; 95% CI, 0.14-3.84; I2 = 0%). Although T/PCM-ESD was associated with a significantly lower risk of perforation (RR, 0.21; 95% CI, 0.06-0.80; I2 = 0%), post-ESD bleeding rates were not significantly different.

CONCLUSIONS

T/PCM-ESD facilitates faster and safer gastric ESD than C-ESD, with similar en-bloc resection, R0 resection, and recurrence rates. A future randomized controlled control trial is required.

A prospective randomized trial comparing the pocket-creation method and conventional method of endoscopic submucosal dissection in early gastric cancers and precancerous lesions

BACKGROUND

Endoscopic submucosal dissection (ESD) is widely used as a standard treatment regimen for early gastric cancers (EGCs). However, such an approach is time consuming and has a high risk of perforation and bleeding in some corner-site lesions because of the obscured view and difficulty in submucosal lifting. The newly developed pocket-creation method (PCM) provides a clearer view and better traction of the submucosal layer than conventional ESD (c-ESD). Nevertheless, no prospective randomized study has evaluated the efficacy of the PCM in EGCs and precancerous lesions.

METHODS

This was a prospective randomized controlled trial. Patients with superficial gastric neoplastic lesions ≥ 20 mm were randomly assigned to the PCM-ESD group or c-ESD group. The primary outcome was dissection speed.

RESULTS

There were 28 patients in the PCM-ESD group and 27 in the c-ESD group. The median dissection speed was significantly higher in the PCM-ESD group than in the c-ESD group (21.5 mm2/min vs 14.3 mm2/min, P < .001). Meanwhile, the operation time in the PCM-ESD group was significantly shorter than that in the c-ESD group (30 vs 40 min, P = .047). In multiple linear regression analysis, the treatment method was independently associated with the resection speed of ESD.

CONCLUSION

PCM-ESD was an effective and safe treatment for EGCs and precancerous lesions.

Comparison of endoscopic submucosal dissection outcomes between early gastric cardiac and non-cardiac cancers: a retrospective single-center study

OBJECTIVES

This study aims to compare the efficacy of endoscopic submucosal dissection (ESD) between early gastric cardiac cancer (EGCC) and early gastric non-cardiac cancer (EGNCC), and investigate associated risk factors for non-curative resection.

METHODS

Early gastric cancer (EGC) patients who underwent ESD from January 2015 to September 2020 in Beijing Friendship Hospital were consecutively enrolled. The clinical, histopathological and endoscopic data were retrospectively analyzed. The study was registered in Chinese Clinical Trial Registry (ChiCTR1800017117).

RESULTS

Among 500 patients with 534 EGC lesions, 117 patients with 118 lesions were allocated to the EGCC group, and 383 patients with 416 lesions to the EGNCC group. The rates of en bloc resection, complete resection and curative resection in the EGCC group were 97.5%, 78.8% and 71.2%, respectively, significantly lower than those in the EGNCC group (99.8%, 94.5% and 90.4%, p = .010, <.001 and <.001). Among non-curative resected lesions, EGCC had more cases in both endoscopic curability (eCura) C-1 and C-2 groups than EGNCC (10.2% and 18.6% vs. 2.4% and 7.2%, p < .001). Multivariate analysis showed that tumor size (OR 2.393, 95% CI 1.388-4.126) and submucosal invasion (OR 11.498, 95% CI 3.759-35.175) were risk factors for non-curative resection in the EGCC group. For EGCC larger than 3 cm, none achieved curative resection, 86.7% were classified as eCura C-2 and 46.7% exhibited deep submucosal infiltration.

CONCLUSIONS

The curative resection rate of ESD for EGCC was lower than that for EGNCC. ESD for EGCC larger than 3 cm should be cautiously considered.