We appreciate the interest from Fernández-Esparrach et al. in our manuscript titled “Predictors of long-term outcomes of endoscopic submucosal dissection of early gastric neoplasia in the West: a multicenter study” [1].

Our data were based on the latest Japanese criteria (5th edition) [2] at the time of data analysis and manuscript preparation. In our manuscript (Supplementary Table 2s), we demonstrated the differential distribution of patients in our cohort according to both the 5th edition and the preceding 4th edition guidelines. This demonstrated the migration of more patients from the expanded criteria (based on the 4th edition) to the absolute criteria (based on the 5th edition), and highlighted the importance of analyzing the data based on the latest available guidelines and evidence.

The Japan Clinical Oncology Group study (JCOG1009/1010) [3], published in 2021, concluded that endoscopic submucosal dissection (ESD) can be a curative and less invasive treatment for undifferentiated cancers <20mm, paving the way to moving this population of patients from the expanded category to the absolute category in the latest Japanese guidelines (6th edition) published in 2023 [4]. Interestingly, only one patient in our cohort would have been in the expanded criteria group based on the 5th edition guidelines (undifferentiated pT1a lesions <20mm), making it very unlikely that our results would have been different if the analysis had been based on the 6th edition guidelines.

It seems that the distribution of patients in our series by indication criteria in general, and the lack of patients in the expanded group in particular, was more indicative of the future direction of patient selection for gastric ESD than in other Western series.

We would, however, agree with the authors in that gastric ESD in the West should be restricted to well-trained endoscopists to ensure comparable outcomes to those in Japan, and that more studies will be needed in the future to further assess the outcomes of gastric ESD in the West in view of the latest available Japanese guidelines.

Article published online:
23 April 2024

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