We thank Shiratori et al. for their interest in our manuscript [1].

We analyzed our data according to the indication criteria of the 5th edition of the Japanese guidelines [2], as this was the latest edition at the time of data analysis and manuscript preparation. Since then, the 6th edition Japanese guidelines [3] have been published, in which undifferentiated pT1a lesions <20mm were moved from the expanded criteria (based on 5th edition guidelines) to the absolute criteria category. However, in our cohort we had only one patient fulfilling these criteria (undifferentiated pT1a <20mm), so we believe the re-analysis of our cohort based on the 6th edition guidelines would not produce significantly different results related to this group of patients.

Regarding the study population, we did not include patients with incomplete endoscopic submucosal dissection (ESD) in our cohort. Given the setting of the regional tertiary units that participated in the study, we agree there will certainly be some patients in the source population (including referring centers) who were eligible for ESD but opted for a different treatment (e.g. surgery) or no treatment based on personal wishes or other factors. However, we did not include this in our analysis because the main focus of our study was to look at the technical and oncosurgical outcomes of ESD in a Western setting. We agree with the authors, however, that it would be interesting to gather some insight into this aspect in the West, and we hope that future Western studies may shed more light on this.

The study was indeed performed at expert high-volume centers, so it may not reflect ESD outcomes from less experienced endoscopists. However, as access to ESD is still largely limited to only a few expert units in Europe, and indeed across the Western world, we still believe the outcomes from our study reflect the current practice in Europe. The question about ESD training in the West is a big and important one, and is beyond the scope of this limited letter, but we refer readers to the European Society of Gastrointestinal Endoscopy curriculum for ESD training [4], in which the authors of our manuscript are generally in agreement.

Given the different healthcare settings and systems in place, there will certainly be some differences in post-ESD management pathways and protocols in Europe compared with the Far East and North America. Most patients in our cohort were only observed overnight and were discharged the next morning with clear dietary advice and appropriate guidance on medications (e.g. proton pump inhibitor medication, restarting anticoagulation or antiplatelet therapy when appropriate). We are not aware of any good quality data to suggest that a more prolonged admission post-ESD reduces the risk of complications. We agree with the authors, however, of the need to further improve R0 resection rates in the West, and we believe this can be achieved mainly through better training on advanced endoscopic assessment with enhanced-imaging techniques to improve the ability of Western endoscopists to delineate subtle and flat gastric neoplasia.

Article published online:
23 April 2024

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