The East in the West

Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the resection of early gastric lesions that is increasingly used for the removal of superficial neoplasias along the gastrointestinal tract. Contrary to endoscopic mucosal resection, ESD allows en bloc resection of lesions > 2 cm, enabling proper pathological assessment. ESD is associated with increased curative rates and reduced recurrence rates, but it is more often complicated with perforation, most of these cases being managed endoscopically. Both techniques have similar bleeding complication rates [1]. In this issue of GE – Portuguese Journal of Gastroenterology, Costa et al. [2] report on the results of 114 gastric ESDs performed in a high-volume center in Portugal. Authors found that gastric ESD is associated with en bloc resection in 96% of all cases, corresponding to R0 resections in 88%, a curative resection was obtained in 83.2%. These excellent results are re-enforced by the fact that the disease-specific survival rate at 12 months was 100%. In this study, most R1 resections were associated with positive lateral margins. That may be explained by the difficulty in delineating lesions in the stomach, where changes in the background mucosa are frequently present, but it may also be associated with the lesion’s characteristics, the nature of the endoscope used, and the ESD technique. All these parameters are prone to improvement. Early detection and proper delineation may be improved not only with the use of high-resolution endoscopes, but also by virtual or conventional chromoendoscopy. This requires optimal equipment and good endoscopic assessment and characterization skills. This work has been developed by several Portuguese gastroenterologists during the last years [3–8]. The improvement in R0 resection rates in the study by Costa et al. [2] may reflect improvements in all these factors. In this study, complications occurred in 13.2% of all ESD procedures. This figure is slightly higher than that in