Denzer

In view of longer life expectancy, endoscopic resection of malignant GI lesions at an early stage is also becoming increasingly important for the elderly. In this patient group, careful preparation with regard to comorbidities, medication, in particular anticoagulants, is essential. In terms of patient safety, general anesthesia will increasingly be required for the resections themselves.

Ebigbo

Elderly and frail patients profit in a special way from the increasing options available to treat early gastrointestinal malignancies. Such patients are often not ideal candidates for surgery. In my opinion, minimal-invasive, endoscopic treatment strategies are ideal options for these patients.

Pioche

We clearly prefer one shot treatment with R0 resection to avoid several examinations with general anesthesia to detect and treat local recurrences. Furthermore, we sometimes accept a low risk of recurrence after endoscopic resections instead of systematic prophylactic surgery.

Schmidt

Endoscopic therapy for early gastrointestinal malignancies for elderly patients is always an individual decision which has to be drawn after thorough discussion with the patient and maybe his relatives. Dedicated guideline recommendations do not exist. Endoluminal endoscopic therapy is an attractive option especially for elderly and frail patients. However, comorbidities, estimated life expectancy and risk of the procedure need to be weighed against the potential benefit of therapy.

Yahagi

Chance of treating elderly patients not only for mucosal cancers but also slightly invasive cancers which are slightly out of indication of ESD is now increasing due to strong demands from the elderly patients for organ preserving minimally invasive treatment. Of course, if there are major risk factors such as lymph vascular invasion or higher tumor budding, we definitely recommend additional surgery after ESD. But if not, we sometimes just observe clinical courses after local complete resection.

Denzer

There is an interdisciplinary consensus in our department that early malignant GI lesions should primarily be resected endoscopically after staging. This is the result of close cooperation with our colleagues from surgery and oncology. This alliance has grown over time through the discussion of current guideline recommendations in our tumor boards and in daily patient care. If endoscopic resectability is questionable, we discuss the case in our interdisciplinary tumor board.

Ebigbo

Malignancies with histological evidence of invasive cancer and borderline resectable lesions are always discussed in a multidisciplinary setting comprising interventional endoscopists, visceral surgeons and GI oncologists. Following resection, case discussions within an interdisciplinary tumor board are conducted to decide on the most suitable follow-up treatment/strategy, of course always guided by current national and international recommendations.

Pioche

There is a dedicated multidisciplinary tumor discussion and the creation of a university diploma for superficial malignancies to increase competency on the treatment and adjuvant management of these tumors.

Schmidt

Every patient with diagnosis of an early GI malignancy is discussed in an interdisciplinary tumor board prior to endoscopic therapy. After endoscopic therapy, further treatment or follow-up is again discussed on the basis of the final histology. Apart from tumor boards, cases are regularly discussed in interdisciplinary radiologic demonstrations and also case- based on the ward and in the clinics.

Yahagi

We usually have multidisciplinary conferences twice a week and discuss the best treatment option for each patient who is scheduled for chemotherapy, chemoradiotherapy, surgery or endoscopic resection.

Denzer

In accordance with our interdisciplinary consensus, we do not present early malignant lesions to our MTB prior to resection. After endoscopic resection, we discuss all resected malignant lesions in our MTB. Here a decision on how to proceed is made, taking into account the histological risk assessment and completeness.

Ebigbo

Yes, definitely. As mentioned above, if there is already histological evidence of cancer, then lesions are discussed in MTB prior to resection. Following resection, optimal treatment strategies are again discussed in within the MTB.

Pioche

In our MTB there is a systematic discussion about the management of superficial cancers including intramucosal carcinomas (but not only dysplasia).

Schmidt

As stated above, MTBs play a crucial role in treatment of early GI malignancies in our institution. Every patient is discussed prior as well as after endoscopic therapy. In case of recurrence during follow-up, further treatment will again be discussed in the MTB.

Yahagi

Yes, MTBs are playing an important role for making a consensus among the specialists to decide the treatment option before intervention. And also, if it turns out to be noncurative resection, we discuss the case again for the further treatment option.

Denzer

An important key to successful training is supervision by an experienced endoscopist, including troubleshooting and feedback. Another key factor is sufficient time for training and adequate staffing. This is particularly important in times of challenging economic conditions in the healthcare sector. The establishment of training grants would be one way forward here.

Ebigbo

There are guidelines to support training in interventional endoscopy, e.g. the EMR and ESD guidelines of the ESGE. The two key aspects in my opinion include selection of talented endoscopists interested in interventional procedures and close supervision of clinical cases which involves performing interventions together with experienced endoscopists.

Pioche

The current state of training is not enough for us. That is why two different training programmes are proposed: one theoretical on superficial malignancies to become an oncologic endoscopist and one practical with a 1-year training program for ESD.

Schmidt

Key aspects of training in advanced endoscopic resection techniques in my view are (1) thorough knowledge of indication, available studies, and guideline recommendations; (2) training on animal models; (3) systematic and consequent training, supervision, and mentoring by a senior endoscopist. Training must include not only the resection procedure but also the management of complications. The current state of training at least in Germany is not optimal due to the lack of defined structured endoscopic training programs. Hence, quality of training currently strongly depend on local structures and resources in the centers. National societies should define and implement training programs.

Yahagi

Trainees are requested to do preoperative work-up for detailed endoscopic evaluation including WLI, NBI magnification, chromoendoscopy, EUS, and CT scan if it is necessary. And give presentations for the responsible cases during the weekly conference and multidisciplinary conferences. This is a great training step to brush up their skills for diagnosis and also knowledge for indication criteria as well as curative resection criteria of endoscopic resection. Regarding the skills of endoscopic resection, trainees are requested to start from EMR under supervision of a senior doctor and also requested to perform at least 50 ESDs on animal models before starting actual ESD procedure on humans. Then, they can start easy ESD under their supervision and gradually step up to difficult cases. This systematic training works very well.

Denzer

The number of cases is essential, not only for the resection technique itself but also for interdisciplinary complication management and further therapeutic decisions. In my opinion, referral centers with certified qualifications in GI malignancies are the way forward.

Ebigbo

High volume centers usually perform better in all aspects of patient care and outcomes. Interventional endoscopists should undergo training in such centers. Case load is highly relevant for the quality of treatment and highly specialized procedures must be limited to referral centers. Centers not able to achieve a particular case load should not be approved for such complex treatment modalities.

Pioche

In our center, endoscopic resections are shared with trainees, who perform ca. 20% of the cases (the others are too difficult). Therefore, we think that a minimum of 100 ESDs per year per center is required to allow for an adequate training. Referring to high volume centers with expertise seems mandatory but is not clearly defined yet.

Schmidt

Studies have clearly shown that caseload for complex procedures like ESD is important to ensure quality. Pooling cases in referral centers will be necessary in the future to ensure optimal patient care. National societies (or politics) may define minimum quantities for complex procedures as it was already done in visceral surgery (e.g. for esophageal resection).

Yahagi

Enough case volume is necessary to keep good clinical outcomes. Especially for ESD, at least 100 cases/year (around 2 cases/week) would be needed to serve as an advanced care center. Actually, we usually have 600–700 ESD cases/year, including very challenging cases at Keio University Hospital; therefore, we can keep extremely high levels of performance.

Denzer

Participation in clinical studies is essential to investigate the clinical value of a resection technique. Under everyday conditions, this is sometimes challenging, as study implementation and documentation need more time and personnel. Otherwise, in my opinion and experience, patients participating in clinical trials tend to have advantages in treatment quality and long-term surveillance, as each step is standardized and carefully monitored.

Ebigbo

Multicenter studies are crucial to produce data that will ultimately guide patient care. However, I am also aware of the fact that the quality of multicenter studies can vary and may even be biased. Overall, centers should be motivated to participate in multicenter studies; most participating centers are more aware of current treatment modalities. In my opinion, all patients presenting for specialized treatment of GI malignancies should be included in multicenter studies.

Pioche

We work a lot on ESD, and ESD is our first treatment option to reduce recurrences and send back the patient to conventional follow up after a single resection procedure. It allows to avoid early follow up in our referring center and to avoid recurrence management with advanced resection. Patients usually prefer a slightly higher risk but therefore a reduction of the number of required colonoscopies. Therefore, it was not so easy to accept piece-meal EMR studies with a more intensive follow up. Currently we are working on projects on bleeding prevention or different techniques of ESDs compared together and therefore it is easier to enrol patient with a single R0 resection in both groups.

Schmidt

Treating patients within multicenter studies is a major part of our daily practice. I think it is very important to participate in such studies and to actively recruit patients. Ultimately, it will improve our knowledge and the generated evidence will optimize treatment and affect clinical outcomes. Advantages of participating institutions include better access to novel techniques and devices, knowledge exchange and close collaboration with other centers, scientific reward in terms of authorships, and also sometimes financial benefits. However, participation in studies always means significant extra workload and requires a strong individual motivation. Local resources, especially in non-academic centers should be taken into account.

Yahagi

Multi-center studies are very important to prove the efficacy of some techniques, however, sometimes cumbersome. We can prove the efficacy of a new technique but it usually takes a long time and a lot of effort. And unfortunately, some of our highly advanced original techniques cannot be reproduced even at other leading institutions since it is highly dependent on individual skills and experiences. That means, organizing a multi-center study is very difficult for highly advanced techniques even if we are already achieving very good clinical outcomes.

Denzer

Over the last 10 years, I have significantly developed my resection skills for early malignancies of the GI tract. The ESD technique in particular has led to my implementation of oncological en bloc resection for early GI malignancies, aligned with surgical quality standards. Today, it is no longer conceivable for me to resect early GI malignancies using the piece meal technique.

Ebigbo

More detailed inspection of GI malignancies prior to resection and a shift from piecemeal to en bloc resections. Overall, the boundaries of endoscopic resections have moved toward more endoscopy and less surgery.

Pioche

The main change is the development of R0 resection for most cases with ESD spreading and the better knowledge on recurrence risk allowing to reduce the number of systematic surgery after endoscopic resection for T1 cancer.

Schmidt

In the last decade, a huge amount of evidence was added to our current knowledge. Large-scale cohort studies and even randomized controlled studies have been published on EFTR, EMR and ESD. Such studies led to the introduction of novel devices and techniques (e.g. EFTR) into daily clinical practice. Furthermore, evidence on existing techniques was published and has already lead to more tailored approaches to different lesions. For example, cold snare piecemeal EMR for SSLs is a promising technique to improve safety with comparable efficacy of conventional EMR. Moreover, simple adjunctive techniques like margin ablation have significantly improved clinical outcomes in terms of recurrences. Modifications of ESD techniques (like tunneling or countertraction) have strongly facilitated the procedure.

Yahagi

Since the risk factors for LN metastasis became much clearer than before, the chance of performing diagnostic resection for borderline cases is increasing. And final judgment can be made referring to common major risk factors after obtaining histopathological results. Also, endoscopic full thickness resection for the small sized GIST less than 3 cm is getting popular now.

K.K., M.J.B., U.D., A.E., M.P., and N.Y. declare no conflict of interest.

A.S.: Ovesco Endoscopy – lecture fees and study grants; Olympus – lecture fees; Fujinon – lecture fees; KLS Martin – consultant.

PD Dr. med. Konstantinos Kouladouros

Central Interdisciplinary Endoscopy

Department of Hepatology and Gastroenterology

Charite University Hospital Berlin

13353 Berlin, Germany

konstantinos.kouladouros@charite.de

Prof. Dr. Michael J Bourke

Department of Gastroenterology and Hepatology

Westmead Hospital, and Westmead Clinical School

University of Sydney School of Medicine

University of Sydney, Sydney, NSW, Australia

michael@citywestgastro.com.au

Prof. Dr. Ulrike Denzer

Division of Interdisciplinary Endoscopy

Department of Gastroenterology

University Hospital Marburg

35043 Marburg, Germany

uwdenzer@gmail.com

Dr. Alanna Ebigbo

Department of Gastroenterology

University Hospital of Augsburg

86156 Augsburg, Germany

Alanna.Ebigbo@uk-augsburg.de

Prof. Dr. Mathieu Pioche

1. Department of Endoscopy and Hepatogastroenterology

Pavillon L, Edouard Herriot Hospital

Lyon, France

2. Lyon 1 University

Lyon, France

Mathieu.pioche@chu-lyon.fr

Prof. Dr. Arthur Schmidt

Department of Gastroenterology,Hepatology and Endocrinology

Robert Bosch Hospital/Robert Bosch Health Campus

70376 Stuttgart, Germany

Arthur.Schmidt@rbk.de

Prof. Dr. Naohisa Yahagi

Division of Research and Development for Minimally Invasive Treatment

Cancer Center

Keio University School of Medicine Graduate School of Medicine

Tokyo, Japan

Yahagi.keio@gmail.com