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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTg5MTY1OS1vdmVydmlldw==\nEndoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)\nAuthor: Raymond E Kim, MD; Chief Editor: Kurt E Roberts, MD more...\nSections Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)\nApproach Considerations\nEndoscopic Mucosal Resection (EMR)\nEndoscopic Submucosal Dissection (ESD)\nPostprocedural Care\nEndoscopic mucosal resection\nEndoscopic mucosal resection (EMR) is a technique used for the staging and treatment of superficial neoplasms of the gastrointestinal (GI) tract. This technique was first developed in Japan for the treatment of early gastric cancer (EGC) and has since spread in use throughout the world for various indications, including dysplastic Barrett mucosa and sessile colonic neoplasms. The utility of EMR rests in its ability to do the following:\nProvide accurate histologic staging of superficial GI neoplasms\nProvide a minimally invasive technique for removal of superficial malignancies\nSeveral variations of EMR are currently used, including injection-assisted, cap-assisted, and ligation-assisted techniques. All adhere to the basic principles of identification and demarcation of the lesion, submucosal injection to lift the lesion, and endoscopic snare resection. By virtue of its overall safety and efficacy in appropriately selected patient populations, EMR has become firmly integrated into the diagnostic and treatment algorithms of superficial GI malignancies.\nSome authors have also studied the use of EMR in a procedure known as antireflux mucosectomy (ARMS) to treat refractory gastroesophageal reflux disease (GERD). [1, 2]\nEndoscopic submucosal dissection (ESD) was developed to resect larger tumors and aid in achieving higher rates of en-bloc resection than would be possible with EMR. The main goal of ESD is to achieve an R0 resection. In the United States, ESD is primarily performed in select centers by specialized endoscopists experienced in this technique. ESD is generally indicated for the following [3] :\nTumors that are diagnosed as carcinomas with intramucosal to superficial submucosal invasion\nLesions with submucosal fibrosis that cannot be removed by EMR even if smaller than 20 mm\nCases where a snare is unlikely to enable a successful en-bloc resection with EMR\nRemoval of large polyps, early colorectal cancer, and those lesions that cannot be accessed transanally in patients who wish to avoid major surgical resection\nEndoscopic and ultrasonographic characterization of lesions\nSeveral classification systems for the staging of early GI cancers that may aid in the prediction of lymph node metastases have been developed. Much of this work was pioneered by Japanese gastroenterologists for the staging and treatment of EGC. The Japanese Society of Gastroenterology (JSGE), working from large databases of EGC resections, classified lesions according to their endoscopic features and the implied risk of mural invasion. [4]\nThe subsequent Paris classification, developed in 2002 at an international consensus meeting, echoed the structure of the JSGE system. In this classification, superficial (type 0) lesions are divided into polypoid (0-I) and nonpolypoid categories (0-II), which are further subcategorized as pedunculated (0-Ip), sessile (0-Is), slightly elevated (0-IIa), flat (0-IIb), slightly depressed (0-IIc), or excavated (0-III). [5] (See the image below.)\nParis classification of superficial gastrointestinal neoplasms.\nIn the Vienna classification, lesions are divided into two broad categories, noninvasive (low-grade dysplasia, high-grade dysplasia [HGD]) and invasive (intramucosal cancer, cancer that infiltrates the submucosa). [6]\nThe mucosal layer is divided into upper, middle, and lower layers: m1 (epithelium), m2 (lamina propria), and m3 (muscularis mucosae). The submucosa is similarly divided into three layers: sm1, sm2, and sm3. Submucosal tumor involvement of 500 μm or less below the muscularis mucosae is characterized as sm1 (superficial) disease, and involvement past 500 μm is categorized as sm2-3 (deep) disease. [5, 7] The sm1 layer is further divided into sublayers a, b, and c on the basis of the lateral spread within the layer. (See the image below.)\nSchematic of lesion penetration as determined by high-frequency endoscopic ultrasonography (EUS).\nHigh-frequency (≥20 MHz) endoscopic ultrasonography (EUS) produces an image of the mucosal wall comprising nine separate layers differentiated by their echogenicity. By carefully examining the depth of lesion penetration into the mucosal and submucosal layers, one may determine the risk of lymph node metastases with greater precision. [8]\nEUS has excellent sensitivity and specificity in accurately diagnosing the tumor depth and lymph node status of esophageal cancer [9] and is considered the most accurate imaging modality currently available. Its accuracy ranges from 75% to 82% for T1 disease, from 88% to 100% for T4 disease, and from 72% to 80% for lymph node involvement. [10]\nA study assessing staging with radiologic and pathologic correlation in patients with esophageal cancer with lymph node metastases who were radiologically staged as N0 reported that whereas EUS, contrast-enhanced (CE) computed tomography (CT), and positron emission tomography (PET)/CT were all more likely to understage nodal disease, PET/CT was more likely to do so than EUS was. [11] The accuracy, sensitivity, and specificity of EUS for N0 vs N+ disease were 55.4%, 42.6% and 75%. Most lymph nodes (82%) were smaller than 6 mm, making direct visualization challenging with current imaging techniques (probably the main reason for the discrepancy between radiologic and pathologic staging).\nFalse-positive EUS images are attributed to peritumoral inflammation, whereas false-negative staging is often due to the microscopic spread of tumor not detectable by EUS. Micrometastases have been found in lymph nodes of early esophageal tumors (as many as 44% in one study [11] ​). Because of the limitations of the technology, EUS is subject to significant rates of false positive and negative disease; however, EUS followed by EMR and histopathologic analysis remains the standard of care for early esophageal cancer staging.\nEndoscopic resection may be considered for definitive treatment of superficial premalignant and well-to-moderately differentiated malignant lesions of the GI tract in the absence of lymph node or distant metastases (T1mN0M0). They also play an integral role in the staging algorithm of early GI cancers by providing a larger resection specimen than standard forceps biopsy, allowing accurate T staging and establishing the presence of lymphovascular involvement. [12] Furthermore, pathologic examination of resected specimens frequently leads to significant alterations in patient management. [13]\nEsophageal lesions\nSquamous cell carcinoma of esophagus\nEMR is reserved for lesions smaller than 2 cm that are limited to esophageal mucosa (corresponding to stage T1a) and involve less than one third of the esophageal circumference. Larger lesions may be treated with ESD. Disease-specific survival rates are as high as 95%, and complication rates are low. [14, 15, 16] In a retrospective cohort of 300 patients with esophageal squamous cell carcinoma (SCC) who underwent ESD or EMR, local recurrence was 1% with ESD and 10% with EMR; however, at 4-year follow-up, there was no difference in survival. [17] EMR and ESD may be performed for staging of lesions lacking architectural or EUS features suggestive of deep submucosal invasion.\nAdenocarcinoma of esophagus\nESD can be used for early adenocarcinoma of the esophagogastric junction (EGJ). Several case series have retrospectively evaluated the role of ESD for non-Barrett adenocarcinoma of the EGJ. [18, 19, 20] The rate of en-bloc resection was 100%, with curative resection rates of 68-79%. Patients with noncurative resections were typically managed surgically. In studies involving mean follow-up durations of 15-30 months, patients with curative ESD resections had no local recurrences or metastatic cancer; in studies involving longer follow-up periods, a 5-year disease-specific survival rate of 100% was reproted for patients with curative resections.\nBarrett esophagus with dysplasia and early adenocarcinoma\nEMR should be used in segments of Barrett esophagus (BE) with mucosal irregularities, including nodularity, ulceration, or flat but irregular mucosal contour. This allows more accurate staging of the lesion, as well as potential therapeutic benefit if a lesion is completely resected. Accurate pathologic staging, the potential for cure, and a favorable safety profile are all reported advantages of EMR in this setting. [21, 22, 23, 24]\nAs with squamous neoplasms, EMR is considered definitive therapy for cancer if the lesion is well-to-moderately differentiated, is limited to the mucosal layer, is 2 cm or smaller, and has no lymphovascular invasion. If an EMR specimen is a definitively resected Barrett cancer or shows only HGD, endoscopic ablative therapy of the remaining BE should be performed. If the EMR specimen demonstrates neoplasia at the deep margin, residual neoplasia should be assumed, and surgical or systemic therapy (chemotherapy, radiation, or a combination of the two) should be considered. [25]\nInvestigations have demonstrated the efficacy of EMR applied to the treatment of larger lesions, as well as the complete eradication of BE with favorable results (albeit with potential increases in complications). [26]\nGastric lesions\nEarly gastric cancer\nAs an established alternative to surgery, guidelines for the use of EMR in the treatment of EGC have been published by the JSGE. [27]\nWell-to-moderately differentiated tubular and papillary adenocarcinomas are classified as differentiated cancers, whereas signet-ring cell carcinomas and poorly differentiated adenocarcinomas are classified as undifferentiated cancers. Indications for endoscopic resection are classified as absolute, expanded, or out of indication and are based on the following:\nDepth of invasion\nFinding of ulceration (UL)\nLesion size\nClassification as differentiated vs undifferentiated\nAbsolute indications for endoscopic resection include the following:\nMacroscopically intramucosal (cT1a) differentiated carcinomas measuring less than 2 cm in diameter\nMacroscopic type does not matter but no ulceration scar (UL[–])\nExpanded indications include the following:\nUL(–) cT1a differentiated carcinomas greater than 2 cm in diameter\nUL(+) cT1a differentiated carcinomas less than 3 cm in diameter\nUL(–) cT1a undifferentiated carcinomas less than 2 cm in diameter\nFactors determining whether EMR or ESD is indicated include the following:\nHistopathologic type\nPresence or absence of ulceration\nGiven the risk of incomplete resection with EMR for lesions with expanded indications, ESD is recommended by the JSGE as the preferred modality. There have been no randomized controlled trials comparing clinical outcomes between gastric EMR and ESD.\nIn a Japanese retrospective gastric cancer registry of 12,647 patients comparing short- and long-term outcomes of EMR and ESD, 81% of patients underwent ESD and 19% underwent EMR. [28] En-bloc and R0 resections were achieved in 79% and 89% of patients undergoing EMR and ESD, respectively. The total proportion of patients who underwent curative resection was 69%; 44% underwent curative resection for absolute indication lesions, and 25% underwent curative resection for expanded indication lesions.\nIn this study, the 5-year overall survival rate was 92% in patients with absolute indications and 90% in those with expanded indications after curative resection and 87% in those undergoing non-curative resection. [28] The 5-year disease-specific survival rates were 99.9% for absolute indications and curative resection, 99.7% for expanded indications with curative resection, and 98.7% for noncurative resections.\nThe standard treatment for expanded-indication lesions, however, remains surgery.\nDuodenal lesions\nEMR and ESD have been used in the treatment and staging of ampullary and periampullary adenomas, early carcinomas, and ampullary submucosal lesions. Additional applications include nonampullary adenomas, neuroendocrine tumors, and submucosal lesions. Available evidence suggests that duodenal EMR and ESD may be associated with a substantial rate of complications, particularly in the treatment of submucosal lesions.\nColorectal lesions\nEMR and ESD are commonly used for the resection of laterally spreading benign or malignant lesions of the colon, including early-stage colon and rectal cancers, flat adenomas, large superficial colorectal tumors, and rectal carcinoids. Additional indications also include those patients who refuse surgical intervention or in whom significant comorbidities are prohibitive. Appropriate indications for EMR include the following [29] :\nWell-differentiated or moderately differentiated tumors confined to the mucosa\nType 0-IIa lesions smaller than 2 cm\nType 0-IIb lesions smaller than 1 cm\nType 0-IIc lesions smaller than 1 cm\nFor large lesions, whose size exceeds half of the circumference of the colorectal lumen, piecemeal EMR should be avoided, and ESD or a surgical resection should be performed. [30] ESD provides a higher curative resection rate with a lower recurrence rate for colorectal tumors larger than 2 cm.\nIn 2015, the JGES published guidelines for colorectal EMR/ESD, including the following recommendations [30] :\nIn nonmalignant lesions, endoscopic resection is recommended for adenomas 6 mm or larger\nResection is recommended for superficial depressed-type lesions (type 0-IIc) even when the lesion is 5 mm or smaller\nAmong early colorectal carcinomas (Tis/T1), lesions with little possibility of lymph node metastasis and a higher expectancy of curability with en-bloc resection on the basis of size and location are usually treated endoscopically\nObvious clinical T1b carcinomas (submucosal invasion depth ≥1000 μm) are usually treated surgically\nWhen endoscopic treatment is performed for colorectal carcinomas, en-bloc resection is the principal approach; however, piecemeal EMR is permissible for some adenomatous and “carcinoma in adenoma” lesions when appropriately carried out and when the possibility of submucosal invasion can be definitively excluded.\nContraindications include the presence of or a high index of suspicion for lymph node or distant metastases.\nBiopsy of the lesion before endoscopic resection (including ESD and EMR) may result in a false-positive result as a consequence of fibrosis at the biopsy site. Because the result of mucosal biopsies is unlikely to alter treatment algorithms, biopsy prior to referral for ESD/EMR should be avoided. If biopsy is undertaken, minimization of the time interval between biopsy and endoscpic resction may help reduce false-positive results. [31]\nThe nonlifting sign, defined as the failure of a lesion to elevate above the surrounding mucosa after submucosal injection underneath the lesion, has been established as a highly accurate and specific predictor of submucosal invasion by colonic lesions. [32] Regarding mucosal lesions with a nonlifting sign and residual or recurrent lesions, ESD often can resect those lesions for which EMR is generally difficult and for which en-bloc resection is desirable. [30]\nThe presence of coagulopathy is a relative contraindication, in view of the risk of bleeding. Any contraindication that applies to standard endoscopy (eg, severe cardiopulmonary comorbidities) is also applicable to ESD and EMR.\nThe key curative difference between surgical and endoscopic resection of cancer is the lack of lymph node dissection with endoscopic resection. Therefore, endoscopic resection is not considered in lesions with more than a negligible risk of lymph node metastasis. Tumor depth of invasion correlates with risk of lymph node metastasis (see Table 1 below). [33, 34]\nTable 1. Lymph Node Metastasis Risk for T1 Tumor at Different Sites in Gastrointestinal Tract [33] (Open Table in a new window)\nEsophageal Squamous Cell Carcinoma\nEsophageal Adenocarcinoma\nColonic Adenocarcinoma\nM1 0% 0% 0-0.4% 0%\nM2 0.03%\nM3 9% 0.02%\nSm1 15-20% 200 μm 1.9% (if lesion is < 2 cm) up to 500 μm < 3% 1000 μm < 1%\n10% without risky signs\n33% with risky signs\n~20% 6%\nSm3 14%\nProcedural planning\nGiven the increasing risk of lymph node metastases associated with deeper tumor invasion into the wall, determination of the depth of lesion penetration is an integral step before endoscopic resection is considered.\nThe following two methods can be used to predict the depth of penetration:\nAnalysis of the endoscopic mucosal features of the target lesion (see the first image below)\nPre–endoscopic resection routine EUS and high-frequency EUS using a miniprobe (see the second image below)\nEndoscopic view of superficial gastric neoplasm.\nProbe-based high-frequency ultrasound image of superficial gastric neoplasm.\nCertain lesion characteristics detectable on endoscopy (see Background) have been associated with risk of submucosal invasion, including the following [35] :\nDepression of the lesion [5, 36] (type IIc in the Paris classification)\nSize greater than 15 mm\nFailure to lift with submucosal injection of saline (see Contraindications)\nSmooth nonindented circumference for elevated (0-IIa) or depressed (0-IIc) lesions\nFor those lesions with submucosal invasion, the risk of lymph node metastases is further modified by the presence or absence of lymphovascular invasion on histologic examination. [37] In one study of HGD and early cancer in BE, lymph node metastases were detected in 0%, 23%, and 69% of lesions within the sm1, sm2, and sm3 layers, respectively. [38]\nSeveral retrospective studies of patients with T1b esophageal adenocarcinoma (EAC) undergoing esophagectomy have found that 16-18% of patients have lymph node metastasis and 27-34% have lymphovascular invasion. [39] ​ Studies comparing lymph node metastases between sm1 and sm2-3 disease, all retrospective and including small numbers of patients, have shown conflicting results. [40, 41, 42]\nSimilarly, in a study of more than 3000 patients who had undergone gastrectomy with lymph node dissection for EGC, no lymph node metastases were seen with well-differentiated to moderately differentiated lesions smaller than 3 cm that were confined to the mucosal or sm1 layers without lymphovascular invasion. [43]\nStandard EUS, with a probe frequency of 7.5-12 MHz, is the most commonly used method of determining the presence of lymph node metastases immediately before EMR. Compared with high-frequency EUS, standard EUS provides greater tissue penetration, displaying a five-layer mucosal wall while allowing visualization of locoregional lymph nodes.\nIn evaluating for lymph node metastases in BE-HGD and early-stage Barrett-associated EAC, EUS demonstrated an accuracy of 93% in an early series. [38] In a second study, EUS identified suspicious lymph node metastases in 28% of patients referred for EMR of BE-HGD and BE-EAC, and fine-needle aspiration (FNA) confirmed metastases in 71% of these cases. [44]\nA subsequent study examined the accuracy of staging with radiologic and pathologic correlation in patients who had esophageal cancer with lymph node metastases and who were radiologically staged as N0. [11] EUS correctly identified N0 vs N+ disease in 55.4% of cases. Its sensitivity for identifying N0 vs N+ disease was 42.6%, and its specificity was 75%.\nThe impact of the information provided by EUS beyond that of a careful endoscopic examination has been questioned. [45] As a result, the use of EUS before endoscopic resection has been somewhat controversial. [46, 47]\nThe adoption of ESD in western practice has been limited by its technical difficulty, steep learning curve, and limited learning opportunities. ESD, however, provides several advantages over EMR for appropriately selected patients and is also a valuable technique in removing lesions with submucosal fibrosis from a prior resection. Because it is difficult to perform en-bloc resection with EMR for lesions larger than 20 mm, ESD is also more suitable for these lesions. The ability to predict depth of invasion in an attempt to decide whether to pursue EMR, ESD, or surgical resection remains difficult to achieve.\nESD is a technically demanding modality for endoscopic resection, carrying an increased risk of adverse events. In the case of colonic ESD, challenges include the following [48] :\nDifficulties achieving scope stability as a consequence of looping\nPeristalsis, flexures, and folds making manipulation of the knife challenging\nThin colonic wall allowing little margin of error during dissection\nRisk of peritonitis from a perforation\nHybrid techniques using ESD to perform a circumferential mucosal incision with partial submucosal dissection, followed by EMR, can also be used where either complete ESD is too technically challenging or sufficient expertise to achieve en-bloc resection is lacking.\nResection of a lesion with ESD can result in the creation of a large mucosal defect that can cause delayed adverse events (eg, bleeding or perforation) after the procedure. There appears to be a learning curve with ESD, and complications decrease as the endoscopist's experience increases. When small perforations occur, endoscopic clipping or suturing can be used to close the site. In more severe cases or situations where endoscopic closure cannot be accomplished, surgical intervention is often needed.\nA key technical consideration for ESD is procedure time. Because ESD is a technically challenging procedure, it can have a significantly longer procedure time than EMR does. In addition, patients may require admission for observation after ESD. Finally, the availability of expert endoscopists with experience in performing ESD is limited in Western practice, as is access to appropriate training opportunities.\nComplication prevention\nEMR and ESD should be performed by experienced operators in a center of expertise. Appropriate adjuncts to treatment should be readily available in the procedure room (see Periprocedural Care). Additionally, interventional radiology and surgical backup should be available in the event of uncontrolled hemorrhage or perforation.\nA number of studies have compared EMR and ESD with other approaches to cancers in various regions of the alimentary tract.\nESD vs EMR\nIn large retrospective series that evaluated ESD for non-Barrett EGJ adenocarcinoma, the rate of en-bloc resection was 100%, with curative resection rates of 68-79%. [18, 19, 20] Patients with curative ESD resections had no local recurrences or metastatic cancer detected in mean follow-up durations of 15 months to 5 years.\nA retrospective cohort study of 300 patients with early SCC who underwent ESD or EMR excluded all patients found to have histologic evidence of submucosal invasion. [17] This study reported en-bloc resection rates of 100% for ESD (mean lesion size, 30 mm) and 53% for EMR (mean lesion size, 20 mm). Local recurrence was lower in the ESD group (1%) than in the EMR group (10%). There was no difference in survival at a follow-up of more than 4 years.\nAnother retrospective series of 70 patients with SCCs 2 cm or larger showed that there was no recurrence of lesions treated by en-bloc resection and that lesions treated with EMR had a significantly higher recurrence rate than lesions treated with ESD. [49]\nLarge retrospective series evaluating ESD for early gastric adenocarcinoma reported en-bloc resection rates of 86-97%, R0 (negative lateral and vertical margins) rates of 88-93%, and local recurrence rates of approximately 1%. The studies showed a high 5-year overall survival (96-100%) with a remarkable 5-year disease-specific survival (99-100%). [50, 51, 52, 53, 54]\nTwo meta-analyses of ESD versus EMR for treatment of EGC reported en-bloc resection rates of 92% for ESD and 52% for EMR; R0 resection rates of 82-92% for ESD and 42-43% for EMR; and local recurrence rates of 0.8% for ESD and 5.0-6.4% for EMR. [55, 56]\nLarge retrospective series comparing EMR with ESD for colorectal tumors larger than 2 cm showed that in the ESD group, the lesions were larger (29-37 mm vs 22-28 mm), en-bloc resection rates were higher (84-95% vs 33-57%), and local recurrence rates were lower (0-2% vs 12-26%). [57, 58, 59, 60]\nESD vs transanal endoscopic microsurgery\nOne retrospective study compared ESD and transanal endoscopic microsurgery (TEM) for Tis or T1 rectal cancers. [61] Patients treated with ESD (n = 30) and those treated with TEM (n = 33) had similar rates of en-bloc resections (96.7% vs 100%) and R0 resections (96.7% vs 97.0%). Neither group had local recurrences or distant metastases. ESD was associated with a shorter total procedure time and a shorter hospital stay than TEM was.\nA meta-analysis that included data from from 11 ESD and 10 TEM series (N = 2077) evaluated outcomes in the treatment of rectal neoplasms larger than 2 cm. [62] TEM was associated with higher rates of en-bloc resection (99% vs 88%) and R0 resection (89% vs 75%) than ESD was, but a higher percentage of lesions in the ESD group were cancers as compared with those in the TEM group, which were mostly adenomas. Also, there was a trend toward fewer local recurrences in the ESD group than in the TEM group (2.6% vs 5.2%). [62, 33]\nESD vs laparoscopy-assisted colorectal surgery including lymphadenectomy\nA large retrospective series from the National Cancer Center in Tokyo evaluated 589 patients (297 patients with colorectal intramucosal or slightly submucosal invasive cancers undergoing ESD; 292 patients with T1 colorectal cancers undergoing laparoscopy-assisted colorectal surgery [LAC]). [63] In this study, ESD was associated with a lower complication rate than LAC, with favorable en-bloc and curative resection rates.\nPeriprocedure\nYoo IK, Ko WJ, Kim HS, Kim HK, Kim JH, Kim WH, et al. 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Aspiration of tissue during ligation-assisted EMR.\nSuperficial gastric neoplasm (arrow) demonstrated with chromoendoscopy prior to cap-assisted endoscopic mucosal resection (EMR).\nEndoscopic mucosal resection (EMR). Combined cap-and-snare device.\nThis video, captured via esophagogastroduodenoscopy, shows use of HALO 90 device to perform radiofrequency ablation in patient with Barrett esophagus. Barrett esophagus increases risk of developing esophageal cancer. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.\nThis video shows circumferential Barrett esophagus via esophagoscopy. HALO 360 device is in esophageal lumen, ready to perform radiofrequency ablation. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.\nThis video, captured via esophagoscopy, shows Barrett esophagus after having just undergone treatment with radiofrequency ablation using HALO 360. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.\nThis video, captured via esophagoscopy, shows long circumferential segment of Barrett esophagus. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.\nEndoscopic submucosal dissection (ESD). Mucosal lesion defined with high-definition white-light imaging.\nEndoscopic submucosal dissection (ESD). Thermal mucosal marking of lesion.\nEndoscopic submucosal dissection (ESD). Circumferential mucosal incision.\nEndoscopic submucosal dissection (ESD). Submucosal dissection.\nEndoscopic submucosal dissection (ESD). Completion of submucosal dissection\nEndoscopic submucosal dissection (ESD): stomach.\nTable 1. Lymph Node Metastasis Risk for T1 Tumor at Different Sites in Gastrointestinal Tract [33]\nRaymond E Kim, MD Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine; Head, Division of Gastroenterology and Hepatology, University of Maryland Midtown Campus\nRaymond E Kim, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy\nFariha H Ramay, MD, MBA Advanced Therapeutic Endoscopy Fellow, Gastroenterology and Hepatology Fellow, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, University of Maryland School of Medicine\nFariha H Ramay, MD, MBA is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Women in Interventional Endoscopy\nBabak Torabi Sagvand, MD Fellow, Division of Gastroenterology and Hepatology, University of Maryland Medical Center\nBabak Torabi Sagvand, MD is a member of the following medical societies: American College of Gastroenterology, American Medical Association\nKurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine\nKurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons\nBruce D Greenwald, MD Professor of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine\nBruce D Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy\nMatthew Hudson, MD Fellow, Department of Gastroenterology and Hepatology, University of Maryland Medical System\nWilliam R Brugge, MD Professor of Medicine, Harvard Medical School; Director, Gastrointestinal Endoscopy Unit, Massachusetts General Hospital\nWilliam R Brugge, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, American Pancreatic Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America\nDisclosure: RedPath Grant/research funds Consulting\nRabindra Watson, MD Clinical Instructor, Interventional Endoscopy Services, Division of Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine\nRabindra Watson, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy\nMedscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.\nencoded search term (Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)) and Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)\nNeuroendocrine Tumors Guidelines\nIntestinal Carcinoid Tumor\nEsophageal Leiomyoma\nEsophageal Lymphoma\nSubmucosal Invasive Depth Predicts Lymph Node Metastasis and Poor Prognosis in Submucosal Invasive Esophageal Squamous Cell Carcinoma\nHow to Deal With Large Colorectal Polyps\nSquamous Dysplasia in the Esophagus Tied to Risk of Additional Lesions\nAccording to Gastroenterologists\n5 Liver-Saving Strategies for the New Year\nFrom Licorice to Slippery Elm: What Works for GI Symptoms?\nWill Smith's Colonoscopy Goes Viral, Sends Message\nInflammatory Bowel Disease Clinical Practice Guidelines (2019)\nProton Pump Inhibitors: Placing Putative Adverse Effects in Proper Perspective\nDiseases & Conditions Neuroendocrine Tumors Guidelines\nProcedures Endoscopic Mucosal Resection (EMR)\nDiseases & Conditions Carcinoid Tumor\nDiseases & Conditions Intestinal Carcinoid Tumor"