First North American Guideline for Endoscopic Submucosal Dissection

ASGE has developed the first guideline in North America for the procedure endoscopic submucosal dissection (ESD). 

Led by immediate past Chair Bashar J. Qumseya, MD, MPH, FASGE, the ASGE Standards of Practice Committee considered such factors as patient values, costs and feasibility for treatment of early cancers in the upper gastrointestinal tract in the evidence-based recommendations to be published in the September 2023 issue of Gastrointestinal Endoscopy (GIE), ASGE’s premier, monthly, peer-reviewed research journal.

“Having a quality guideline such as this will be a valued clinical resource to the endoscopy community as ESD becomes an alternative to either endoscopic mucosal resection (EMR) or surgery in the United States for the management of select lesions in the GI tract,” said ASGE President, Jennifer Christie, MD, FASGE.

More than 100 studies were reviewed to determine preference for ESD, EMR or surgery for managing early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric adenocarcinoma (GAC) and their predecessor lesions (abnormal tissue).

“ESD is increasingly being used in the United States for the precise and minimally invasive removal of abnormal or early-stage cancerous lesions from the digestive tract. We are excited to introduce the first ESD guidelines in North America, providing detailed insights into the appropriate utilization of this technique for upper gastrointestinal indications,” said Mohammad A. Al-Haddad, MD, MSc, a lead author and committee member.

ESD and EMR are regarded as safe, effective procedures that have become the first treatment options for patients with early abnormal tissue growth in the gastrointestinal tract, according to the clinical practice guideline. Both procedures are typically less expensive than surgery and require shorter hospitalization.

Generally, EMR is performed to extract lesions smaller than 2 centimeters (cm). The procedure uses a tube (an endoscope) to examine and treat conditions of the digestive tract. Fluid is injected under the lesion to remove it with a snare.

Another minimally invasive procedure that uses an endoscope, ESD cuts with electrosurgical knives, allowing for full removal of larger lesions, which is important for a low recurrence rate. However, as a newer technique than EMR, ESD is often available only at certain centers.

The guideline presents recommendations for procedures based on factors including lesion size, cancer type and invasion depth. Highlights include:

  • ESCC The guideline advises against surgery for esophageal squamous dysplasia (abnormal cells that could lead to cancer) or early ESCC with no sign of invasion into the inner layer of tissue (submucosa), breakage on the lesion’s surface (ulceration) or abnormal appearance (poor differentiated). Mortality was lower among ESD patients than surgery patients in researched studies. ESD is the favored method for potentially completely removable lesions.
  • EAC ESD is favored over EMR for early, well-differentiated, nonulcerated EAC (T1 stage) or nodular Barrett’s dysplasia (raised tissue in Barrett’s esophagus, which is damage to the lower esophagus) larger than 2 cm. Yet, for similar lesions 2 cm or smaller, the guideline suggests ESD or EMR.
  • GAC The guideline prefers surgical removal for poorly differentiated lesions any size.

Read more details at GIE.

“We used the best available clinical evidence to provide patient-centered guidance to physicians on who would best benefit from ESD,” Dr. Qumseya said. “Our recommendations are precise and have been shown to improve patient outcomes like cure from certain gastrointestinal cancers in their early stages.”

ESD plays a significant part in esophageal and gastric cancer treatment, but its safety and efficiency rely on endoscopist expertise and availability. The guideline should not be viewed as a rule or as encouraging, advocating, mandating or discouraging a treatment.

ASGE guidelines on aspects of gastroenterology clinical practice offer best-practice recommendations to help standardize care and enhance outcomes. They are reviewed for updates approximately every five years or when new data may impact a recommendation. This guideline was prepared with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

View All ASGE Guidelines

About Gastrointestinal Endoscopy
Gastrointestinal endoscopic procedures allow the gastroenterologist to visually inspect the upper gastrointestinal tract (esophagus, stomach and duodenum) and the lower bowel (colon and rectum) through an endoscope, a thin, flexible device with a lighted end and a powerful lens system. Endoscopy has been a major advance in the treatment of gastrointestinal diseases. For example, the use of endoscopes allows the detection of ulcers, cancers, polyps and sites of internal bleeding. Through endoscopy, tissue samples (biopsies) may be obtained, areas of blockage can be opened and active bleeding can be stopped. Polyps in the colon can be removed, which has been shown to prevent colon cancer.

About the American Society for Gastrointestinal Endoscopy
Since its founding in 1941, the American Society for Gastrointestinal Endoscopy (ASGE) has been dedicated to advancing patient care and digestive health by promoting excellence and innovation in gastrointestinal endoscopy. ASGE, with almost 16,000 members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education. Visit and for more information and to find a qualified doctor in your area.


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