Hybrid Endoscopic Submucosal Dissection for Early Gastric Neoplasms: An Ideal Technique?

We read with great interest the study by Esaki et al.1Esaki M. et al.Clin Gastroenterol Hepatol. 2022; (Published online November 4, 2022)https://doi.org/10.1016/j.cgh.2022.10.030PubMed Google Scholar In this study, the authors compared the efficiency of hybrid endoscopic submucosal dissection (H-ESD) with conventional endoscopic submucosal dissection (ESD) in early gastric cancer. The results effectively prove that H-ESD can reduce the procedure time. However, we would like to discuss the results further. The ESD procedure time was used as the primary outcome. Considering the design of such studies, it is impossible to blind the endoscopic operators to eliminate the bias caused by subjective judgment. We noticed that there was no mention on minimizing the occurrence of such bias and whether the same endoscopist participated in the operation of both groups. In addition, the authors mentioned that the determination of snaring time depends on the operators’ judgment. All these factors may lead to an exaggerated assessment of efficiency because of possible information bias. H-ESD has been reported as a risk factor for noncurative ESD in some studies.2Fleischmann C. et al.Gastroenterology. 2021; 161: 1168-1178Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 3Chow C.W.S. et al.Surg Endosc. 2022; (Published online 2022)https://doi.org/10.1007/s00464-022-0967 2-2Google Scholar, 4Kang D.U. et al.Colorectal Dis. 2020; 22: 2008-2017Crossref PubMed Scopus (2) Google Scholar Because the primary outcome of this study is different, possible differences in en bloc resection rate and curative resection rate between groups cannot be excluded because of the small sample size derived from the current sample estimation. Furthermore, the efficacy of one resection technique is best evaluated by practical measures that the patient can benefit from, including long-term effectiveness, adverse events, and the need for surgical resection.5Pellise M. et al.Gastrointest Endosc. 2021; 94: 483-485Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Because no follow-up results were available in this study, the difference in recurrence rates between the 2 groups could not be determined. Finally, all gastric cancers included in this study were early lesions that met the absolute indication for both endoscopic mucosal resection (EMR) and ESD, as defined by the guideline of the Japan Gastroenterological Endoscopy Society.6Ono H. et al.Dig Endosc. 2021; 33: 4-20Crossref PubMed Scopus (104) Google Scholar This is understandable given the EMR-like operational characteristics of H-ESD. Because of this, the effectiveness of H-ESD in these lesions still needs to be compared with that of EMR. An EMR is more likely to have a faster procedure time than H-ESD because it does not require the time for a mucosal incision. If their clinical effects are similar, the value added of H-ESD could be reduced. This should be addressed in future studies, to help further understand the role of H-ESD in early gastric cancer.