Endoscopic submucosal dissection (ESD) removes GI tumors with precision, no incisions

Patient with esophageal cancer shares extraordinary story of survival

As a young man in his mid-20s, Jorge Gómez was one of thousands of Cuban citizens who fled Communism and the island country on a raft in 1994. He would spend 11 months living in a tent city at Guantanamo Bay before being granted asylum into the U.S., where he overcame numerous obstacles to build a better life as an engineer and father of four boys in Carrollton, Texas.

Patience, perseverance, and an eternal sense of optimism sustained him throughout his journey, he said. And it served him well in 2021 when, during a routine visit to his primary care physician, a cancerous growth in his esophagus was discovered.

Although he had experienced no symptoms, the prognosis was ominous.

“I was supposed to go on vacation, and I asked the doctor, ‘should I cancel it?’ he recalled. “He said, yes, the sooner the better.”

Heeding his doctor’s recommendation, he sought the help of Markus Goldschmiedt, M.D., Clinical Associate Professor of Internal Medicine in the Division of Digestive and Liver Diseases at UT Southwestern Medical Center, who was building a reputation as one of a handful of specialists in Dallas-Fort Worth who could offer a highly complex procedure known as endoscopic submucosal dissection (ESD).

The minimally invasive technique allows the endoscopist to delicately carve out early-stage tumors and precancerous lesions from the wall of the digestive tract, reducing hospitalization and recovery times. ESD also has lower complication rates than esophagectomy, a more traditional surgical approach that involves removing part of the esophagus.

Dr. Goldschmiedt told Mr. Gómez the size and location of his tumor – approximately 4 centimeters and located near the base of his throat and sternum – would make it challenging to reach, even with the endoscope, a thin, flexible tube with a camera and surgical tools attached to it.

But Mr. Gómez wanted the procedure, which can be curative, so he persisted.  

“I told him I had no other options,” he said, recounting that initial meeting with Dr. Goldschmiedt. “I said, ‘If you don’t see me, I don’t have anywhere else to go.’”

The timing was somewhat serendipitous. In 2019, Dr. Goldschmiedt introduced ESD at UT Southwestern after years of traveling back and forth to China and Japan to train with the pioneers of procedure. He also recruited Thomas Tielleman, M.D., whom he trained as a fellow in advanced endoscopy and who is now part of the ESD team and an Assistant Professor of Internal Medicine. The ESD specialty service really took off in 2020 and provided a major boost to an already nationally ranked gastroenterology and GI surgery program.

Drs. Goldschmiedt and Tielleman continue to hone their technique and, thanks to the support of UT Southwestern, they recently hosted two of the world’s preeminent gastroenterologists and ESD experts from Tokyo, Ken Ohata, M.D., Ph.D., and Yohei Minato, M.D.

“It is one of the most complicated procedures that can be done in the esophagus, stomach, colon, and even the small intestine with the proper skill,” Dr. Goldschmiedt explained. “This is not a widely available option in most places in the United States, and it is primarily found at certain academic centers and a few private practices currently.”

Mr. Gómez, who had managed to escape dire circumstances decades ago, knew he was in the right place at the right time again.  

“When I spoke to Dr. Goldschmiedt, I felt confident,” he said, noting that the two men often conversed in Spanish; Dr. Goldschmiedt is from Peru. “I told him that I was going to fight as hard as the day I left Cuba.”

An enhanced approach to treating GI cancers

Originally developed in the 1990s in Japan, ESD is a highly effective treatment for esophageal neoplasia, or the growth of abnormal tissue in the wall of the digestive tract. One 2017 Annals of Surgery study found it to have a 98% survival rate with less than 3% recurrence of cancer cells.

It is also highly complex with formally trained experts few and far between.

“Having the ability to perform this type of third space endoscopy procedure is critically important because it allows us to remove cancerous tissue early while minimizing disruptions to organ function, and that can potentially make a significant difference in patient outcomes,” Dr. Tielleman said.

Third space endoscopy, also known as submucosal endoscopy, refers to the layers of tissue that comprise the gastrointestinal wall: the mucosa, which lines the lumen of the digestive tract; the muscularis propria, the bands of muscle surrounding the mucosa; and the submucosa, which is the layer between the two.

ESD demands extreme precision and dexterity. The margin of error is razor thin.

“The movements are completely different than traditional endoscopy. Every millimeter you do, there’s a risk for perforation and that can make it very stressful,” said Dr. Goldschmiedt. “It’s not for everybody.”

Fluid is injected in the submucosa under the lesion, lifting it away from the surrounding muscle layer, allowing the endoscopist to mark the borders and then use the surgical knife to separate it from the GI wall. A few millimeters off, and the muscles beneath the submucosal layer could be perforated, which would require endoscopic clips to close the wound and, possibly, follow-up corrective surgery. Fortunately, most incidents can be managed endoscopically or with medication and careful observation, according to one recent medical review.  

Once extracted, the tissue is sent to a pathology lab to be assessed. ESD is a more accurate method of staging cancer than endoscopic ultrasounds, and the results will dictate next steps, said Dr. Tielleman.

“UT Southwestern is unique in that we are considered a high-volume center for ESD, which is defined as more than 50 cases per year. We are on track for more than 120 this year at UT Southwestern and Parkland,” Dr. Tielleman said. “Generally, that means higher success rates and a lower risk of complications.”

When Drs. Minato and Ohata visited UTSW for a week earlier this year, the team scheduled about 20 ESD procedures – a number most academic medical centers might see in a year – to maximize their learning and collaboration opportunities.

“ESD was developed in Japan, but many innovations have come from the United States,” Dr. Minato said. “By collaborating (with UT Southwestern), I can learn a lot from them as well."

Comparing ESD to traditional surgery

ESD is not a one-size-fits-all solution to GI tumors. But for patients diagnosed with early-stage cancer or precancerous growths, it is an appealing option.

“In the right scenario, it can replace an esophagectomy, a gastrectomy, or a colectomy, which can be life-altering surgeries, and allow us to remove the tumor while preserving the organ,” Dr. Tielleman said. “By comparison, traditional surgery is a more involved and complicated process with a much lengthier recovery process.”

While both types of procedures are well-established treatments, ESD has additional benefits. Physicians can remove lesions en bloc rather than one piece at a time. It is a curative treatment for pre-malignant or superficial cancers. And histopathologists can better examine the sample for concerning signs.

“The beauty of ESD is that sometimes we can send the patient home the same day or the next, if everything goes well,” Dr. Goldschmiedt added. “And if everything goes well, there's really no significant post-operative care required.”

But it is not without limitations. The difficulty of removing a tumor depends on several factors, including its size, shape, and position – factors that could heighten the risk of perforation – and physicians might spend anywhere from 40 minutes to several hours making sure it is thoroughly excised.

‘I realized how blessed we are’

In Mr. Gomez’s case, the lesion sat in his upper thoracic esophagus, which presented challenges with maneuverability.

After Mr. Gomez underwent his procedure at UT Southwestern, his health improved, and although he had to follow a liquid diet and stay home from work for a few days, it was a smooth recovery. When Dr. Goldschmiedt performed a follow-up exam a few weeks later, there was no trace of complications or other abnormalities.

Three years later, Mr. Gomez’s health remains clear.

“At 56 years old, I still feel like I’m 20,” he said, laughing. “If you live 26 years in a country like I had before, and then you have the opportunity to live here in the U.S. and have the life I’ve had, it’s hard to say, ‘it’s done.’ So, when I heard cancer, I wasn’t ready to go yet.”

That’s why he was so determined to be treated by Dr. Goldschmiedt and his team.

“I realized how blessed we are, having access to this treatment at UT Southwestern so close to us. Texas is such a huge state, and I have seen other patients arriving with luggage, which probably means they are coming from another region,” he said. “Dr. Markus, he was the one. Everyone told me that. So, I when I looked at him, I knew, ‘you’re the one who’s gonna fix me.’ And he did!”