1 Guidance

Guidance

1.1 Current evidence on the efficacy of endoscopic submucosal dissection (ESD) in patients with oesophageal adenocarcinoma or high-grade dysplasia in Barrett's oesophagus is limited in quantity and there are safety concerns specifically regarding the risk of oesophageal perforation. Therefore, in these patients, the procedure should only be used in the context of research.

1.2 Current evidence on the efficacy of ESD in patients with oesophageal squamous carcinoma or squamous dysplasia is limited. This evidence is mostly from Japan where the epidemiology of oesophageal cancer is different from the UK. There are safety concerns specifically regarding the risk of oesophageal perforation. Therefore, in these patients, the procedure should only be used with special arrangements for clinical governance, consent and audit or research.

1.3 Clinicians wishing to undertake ESD for oesophageal squamous carcinoma or squamous dysplasia should take the following actions.

Inform the clinical governance leads in their Trusts.
Ensure that patients and their carers understand the uncertainty about the procedure's safety and efficacy and provide them with clear written information. In addition, the use of NICE's information for patients ('Understanding NICE guidance') is recommended.
Audit and review clinical outcomes of all patients having ESD for oesophageal squamous carcinoma or squamous dysplasia (see section 3.1).

1.4 Patient selection should be carried out by an upper gastrointestinal cancer multidisciplinary team.

1.5 The procedure is technically challenging and should be carried out only by clinicians with specific training in the technique.

1.6 NICE encourages further research into the procedure. Studies should define clearly the type, grade and stage of cancer or dysplasia being treated. Efficacy outcomes should include adequacy of resection and the proportion of patients free from local recurrence. Safety outcomes should include perforation and stricture, and the consequences of these complications.