ESD Tecnique.

Recently, local treatment for EGC by endoscopic submucosal resection (ESD) has been accepted as a standard treatment strategy for selected cases of EGC.
ESD provides a 5-year survival rate of 85% equivalent to that of surgery and is devoid of traditional surgical morbidity and mortality.

One-piece resection is considered to be a gold standard of EMR as it provides accurate histological assessment and reduces the risk of local recurrence.

The general criteria for ESD in EGC proposed by the Japanese Gastric Cancer Association includes:
1. differentiated adenocarcinoma
2. intramucosal Cancer
3. 20 mm in size; and
4. without ulcer finding.

Lesions that meet all of the above criteria have negligible risk
of lymph node metastasis and have a reasonable tumor size
allowing one-piece resection by conventional EMR.

The expanded criteria  include lesions  
-21 mm and ulcerative lesions which were originally resected by surgery.
By expanding the criteria for EMR as suggested above the
need for gastrectomy in EGC can be reduced, as these
patients could be treated by EMR.

This knife is a modification of traditional needle
knife and has an insulated ceramic tip which reduces the risk
of gastric wall perforation. Over the years we have gained
substantial experience and expertise in the use of this knife
and, for last 5 years, ESD with the IT knife has become a
standard practice in the treatment of EGC at our center.

Our Data.
Operation time.
Median operation time: 60 min. (range; 10–540 min).

Complications
Mortality
There was no death in this large series of patients (mortality rate: 0%).
Immediate bleeding
Evidence of immediate bleeding is 7%.
Delayed bleeding
Delayed bleeding is seen in 6%. Of these patients, 76% bled within 24 h and the remaining 24% bled between 2 and 15 days after the procedure.
All cases of bleeding were controlled by endoscopic treatments
(hemoclipping and/or electrocoagulation) and did not
require any surgical intervention. Blood transfusion was
required in only one patient.

Perforation
Gastric wall perforation occurs in 4%. Metallic clipping is useful to treat satisfactorily 95% of these cases.