![Page 1: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/1.jpg)
Tokyo Medical University
15th Warsaw Gastroenterological Meeting, Warszawa
ESD history and future –simple is hard
Takuji Gotoda, MD, PhD, FASGE
Department of Gastroenterology & Hepatology,
Tokyo Medical University
![Page 2: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/2.jpg)
Incidence map of gastric cancer
KORIACHINA
JAPANCOSTA RICA
CHILE
![Page 3: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/3.jpg)
History of ESD
To improve technical skill
To provide curability, better QOL
![Page 4: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/4.jpg)
Agenda
Technique
Curability
![Page 5: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/5.jpg)
Polypectomy
Soetikno R, Gotoda T et al. Gastrointest Endosc,2003
1970s 1980s 1990s 2000s 2010
![Page 6: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/6.jpg)
EMR
Soetikno R, Gotoda T et al. Gastrointest Endosc,2003
1970s 1980s 1990s 2000s 2010
![Page 7: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/7.jpg)
Technical limitation by EMR
En bloc resection Piecemeal resection
Korenaga D, et al. Br J Surg, 2000
Eguchi T, Gotoda T et al. Dig Endosc, 2003
![Page 8: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/8.jpg)
Local recurrence after piecemeal EMR
Tanabe et al
Author Methods
Strip Biopsy, EAM 3.5% (15/423)
Recurrence rate
Kawaguchi et al Strip Biopsy, EMR-C 35.3% (97/266)
Ida et al EMR+Laser 6.7% (11/165)
Chonan et al EMR 10.9% (21/193)
Hirao et al ERHSE 2.3% (8/349)
Mitsunaga et al Strip Biopsy 18.2% (54/296)
Tanabe S, et al. Gastrointest Endosc, 2002
![Page 9: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/9.jpg)
Original criteria in EMR era
Guideline criteria for EMR
Depth
Histology
Mucosal cancer Submucosal cancer
UL(-) UL(+) SM1 SM2
≦20 20<
≦30 30<
≦30 any size
Differentiated
Undifferentiated
Surgery
![Page 10: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/10.jpg)
Concept of endoscopic resection
EMR/ESD Laparoscopic Open
![Page 11: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/11.jpg)
EGC with no risk of LN metastasis
Conditions
Differentiated adenocarcinomaIntramucosal cancer
No lymph-vascular involvement
Irrespective of ulcer findings
Incidence 95% C.I.
Tumor less than 3cm
Differentiated adenocarcinomaIntramucosal cancer
No lymph-vascular involvement
Without ulcer findings
Irrespective of tumor size
Differentiated adenocarcinoma
Minute submucosal penetration (SM1)No lymph-vascular involvement
Tumor less than 3cm
0/1230 (0%)
0/929 (0%)
0/145 (0%)
0-0.3%
0-0.4%
0-2.5%
Gotoda T, et al. Gastric Cancer, 2000
![Page 12: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/12.jpg)
ESD
Ono H, Gotoda T et al. Gut, 2001
1970s 1980s 1990s 2000s 2010
Polypectomy; Deyhle et al., Endoscopy, 1973 (colon)
Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984
EMR-C; Inoue et al., Gastrointest Endosc, 1993
EMR-L; Akiyama et al., Gastrointest Endosc, 1997
![Page 13: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/13.jpg)
En bloc resection - regardless size, fibrosis and/or location -
well diff. adenoca.,Type 0-IIc, 8x7mm, M, ly0, v0, ul(-)
20x20mm
50x40mm
well diff. adenoca.,Type 0-IIc, 30x25mm, M, ly0, v0, ul-IIs
well diff. adenoca.,Type 0-IIc, 21x17mm, M, ly0, v0, ul-IIs
65x45mm
![Page 14: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/14.jpg)
Expanded criteria in ESD era
Guideline criteria for EMR
Expanded criteria for ESD
Depth
Histology
Mucosal cancer Submucosal cancer
UL(-) UL(+) SM1 SM2
≦20 20<
≦30 30<
≦30 any size
Differentiated
Undifferentiated
Surgery
Gotoda T, et al. Gastric Cancer, 2000
Soetikno R, Kaltenbach T, YehR, Gotoda T. JCO, 2005
Hirasawa T, Gotoda T, et al. Gastric Cancer, 2009
![Page 15: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/15.jpg)
Summary of ESD
ESD
EMR
Gotoda T. Clin Gastroenterol Hepatol , 2005
Large en bloc resection Less local recurrence Precise histological assessment
![Page 16: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/16.jpg)
Ove
rall
surv
ival
standard criteria
expanded criteria
Observation period (months)
standard criteria
expanded criteria
Number of at risk patients 10 20 30 40 50 60
631 584 455 346 264 186
621 559 433 314 242 156
Survival by treatment groups
Gotoda T et al. Br J Surg, 2010
![Page 17: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/17.jpg)
ESD vs. EMR: Rate of Curative Resection
Cao Y et al. Endoscopy, 2009
![Page 18: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/18.jpg)
Local and distant metastasis
3 years later
![Page 19: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/19.jpg)
Possibility of LN metastasis
500μm
April 2005
Category 5.2 Vienna classificationMacroscopic type : 0 IIcSize : 21×10mmDepth of invasion : SM1 ( 500μm )ly0, v0Peptic ulcer : Ul-II
![Page 20: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/20.jpg)
EUS-FNA
December 2007
May 2009
EUS-FNA
Oya H, Gotoda T, et al. Gastric Cancer, 2011
![Page 21: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/21.jpg)
We could cure …
Distal gastrectomy in July 2009
![Page 22: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/22.jpg)
Agenda
Technique
Curability
![Page 23: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/23.jpg)
ESD vs. EMR meta-analysis
Local recurrence was lower with ESD
(OR 0.09, 95%CI 0.04–0.18)
Cao Y et al. Endoscopy, 2009
ESD took longer than EMR (weighted mean
difference [WMD] 1.76; 95%CI 0.60–2.92)
ESD showed higher bleeding and
perforation rates
(OR 2.20, 95%CI 1.58–3.07; OR 4.09, 95%CI
2.47–6.80)
![Page 24: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/24.jpg)
Frequency of complications during ESD - 1534 operations : 2000-2004 at NCCH -
✓ Delayed bleeding ; 4% (63 cases)
✓ Perforation ; 4% (64 cases)
▶ 2000〜 2002 : 6.5% (50/766)
▶ 2003〜 2004 : 1.7% (13/768)
✓ Respiratory complications (atelectasis, pneumothorax) ; 0.3% (5 cases)
Oda I, Gotoda Tet al. Dig Endosc,2005
![Page 25: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/25.jpg)
Endoscopic hemostasis
Soft coagulation mode 80W (ESG-100, Olympus Co.)
![Page 26: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/26.jpg)
Endoscopic closure by metallic clips
Minami S, Gotoda T, et al. Gastrointest Endosc, 2006
Ikehara H, Gotoda T, et al. Br J Surg, 2007
![Page 27: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/27.jpg)
Result of gastric perforation during ESD - 2460 operations : 1987-2004 at NCCH -
121 patients (4.9%) with perforation
4 surgical treatment(1987-1993)
117 endoscopic closure(1994-2004)
2 failure & additionalsurgical treatment
115 success(98.3%)
Minami S, Gotoda T, et al. Gastrointest Endosc, 2006
Ikehara H, Gotoda T, et al. Br J Surg, 2007
![Page 28: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/28.jpg)
Result of ESD
Rösch T, et al. Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy. 36:788-801,2004.
![Page 29: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/29.jpg)
No counter traction
Gotoda T et al. Gastrointest Endosc,2009
Kondo H, Gotoda T et al. Gastrointest Endosc,2004
![Page 30: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/30.jpg)
Magnetic-anchor–guided ESD
Gotoda T et al. Gastrointest Endosc,2009
![Page 31: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/31.jpg)
Counter traction
![Page 32: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/32.jpg)
Recent results of ESD
Rösch T, et al. Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy. 36:788-801,2004.
Catalano F, et al. The modern treatment of early gastric cancer: our experience in an Italian cohort. Surg Endosc. 23:1581-6,2009. Dinis-Ribeiro M, et al. A European case series of endoscopic submucosal dissection for gastric superficial lesions. Gastrointest Endosc. 69:350-5,2009Coda S, et al. A Western single-center experience with endoscopic submucosal dissection for early gastrointestinal cancers. Gastric Cancer. 13:258-63,2010.Parra-Blanco A, et al. Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video). Gastrointest Endosc. 74:1137-41,2011Białek A, et al. Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video). Gastrointest Endosc. 75:276-86,2012
![Page 33: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/33.jpg)
Intelligent fingers in Poland
2008 in Rotterdam 2010 in Tokyo
![Page 34: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/34.jpg)
Training
![Page 35: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/35.jpg)
Limited Global Adaptation of ESD ?
Diagnosis; WL, AIM, IEE, etc
Submucosal Injection
Circumferential Incision
Submucosal Dissection
Pathological Interpretation
Surveillance
Circumferential Incision
Submucosal Dissection
- New devices …..
- Require skilful technique
- Bleeding
- Risk of perforation
- Metal clips
- Time-consuming
- Costly
- No early gastric cancer
![Page 36: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/36.jpg)
Incidence of gastric cancer
![Page 37: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/37.jpg)
Recommended steps for training ESD
• Animal training
• Gastric ESD in distal stomach
• Rectal ESD
• Esophageal ESD
• Gastric ESD in proximal stomach
• Colonic ESD
![Page 38: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/38.jpg)
Endoluminal treatment in new era
2000s 2010
LECS; Hiki et al, Surg Endosc, 2008Laparoscopic and endoscopic cooperative surgery
![Page 39: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/39.jpg)
LECS; Laparoscopic and endoscopic
cooperative surgery
Hiki et al, Surg Endosc, 2008
Blood vessels in the excision area around the tumour were prepared using an ultrasonically activated device (Autosonix; Tyco Healthcare, Tokyo, Japan) and Ligasure (Tyco Healthcare, Tokyo, Japan)
![Page 40: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/40.jpg)
LECS
Hiki et al, Surg Endosc, 2008
These procedures dissected the tumour and only the minimal extra tissue area of the stomach wall.
![Page 41: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/41.jpg)
For patients
Curability
Technical limitation
Treatment
![Page 42: ESD history and future –simple is hard - MEDtube.net€¦ · Endoscopy, 1973 (colon) Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984 EMR-C; Inoue et al., Gastrointest Endosc,](https://reader034.vdocuments.mx/reader034/viewer/2022051602/5ae939167f8b9a6d4f907b61/html5/thumbnails/42.jpg)
Thank you for your kind attention
Simple is hardSteve Jobs
1955-2011