Anesthesiologist’s perspective on endoscopic submucosal dissection: Bridging minimally invasive surgery and enhanced recovery after surgery management

Abstract

In this article, we comment on the recent article by Fang et al. The study highlights that endoscopic submucosal dissection (ESD) offers advantages such as minimal incisions, shorter operative time, reduced bleeding, and faster patient recovery, demonstrating its strong alignment with the principles of enhanced recovery after surgery (ERAS). From an anesthesiologic perspective, ESD contributes to decreased intraoperative stress, thereby reducing opioid requirements. Simultaneously, the shorter procedure duration and minimal tissue trauma mitigate the adverse effects of deep anesthesia on circulatory and respiratory functions, leading to a more stable emergence from anesthesia and smoother endotracheal extubation. Ultimately, the minimally invasive nature of ESD is crucial for minimizing postoperative nausea and vomiting and preventing postoperative delirium. Historically, ERAS protocols have primarily focused on open and laparoscopic surgeries, with a lack of systematic ERAS guidelines for endoscopic treatments. Therefore, anesthesiology departments should take a more proactive role in the perioperative care of patients undergoing endoscopic procedures, spearheading the development of a standardized “ESD-ERAS” pathway.

Key Words: Early gastric cancer; Endoscopic submucosal dissection; Anesthesia management; Enhanced recovery after surgery; Minimally invasive surgery

Core Tip: Compared to laparoscopic gastrectomy, endoscopic submucosal dissection (ESD) offers advantages in treating early gastric cancer, including fewer postoperative complications and shorter hospital stays. From an anesthesiologist’s perspective, ESD procedures reduce postoperative nausea and vomiting, facilitate perioperative anesthesia management, and decrease postoperative delirium in patients. This aligns with the principles of enhanced recovery after surgery. However, no standardized ERAS protocol currently exists for ESD. Therefore, we propose several efforts anesthesiologists can undertake within the enhanced recovery after surgery framework.

TO THE EDITOR

A recent retrospective study comparing the influence of endoscopic submucosal dissection (ESD) and laparoscopic radical gastrectomy on postoperative recovery in patients with early gastric cancer (EGC) or precancerous lesions demonstrated that ESD achieved a higher en bloc resection rate, although the curative resection rate was lower. Final pathological examination after ESD for EGC may reveal certain factors (such as deep tumor invasion or unclear margins) necessitating subsequent surgical resection, thereby reducing the curative resection rate achieved with a single treatment. Postoperatively, patients undergoing ESD experienced faster bowel function recovery, earlier oral intake resumption, shorter hospital stays, and fewer complications[1]. Collectively, these findings highlight the advantages of ESD in minimizing surgical trauma, accelerating recovery, and enhancing perioperative safety, aligning well with the core principles of minimally invasive surgery and enhanced recovery after surgery (ERAS). In the management of EGC, the comparison between ESD and laparoscopic surgery not only reflects differences in surgical approaches but also offers new insights into anesthetic management and perioperative recovery.

WHY ESD FACILITATES ERAS: AN ANESTHESIOLOGIST’S VIEW

The core principle of ERAS is stress reduction, and ESD promotes rapid recovery through multiple mechanisms as follows: (1) The minimal invasiveness of ESD decreases surgical trauma and inflammatory mediator release, thereby reducing postoperative pain intensity, lowering opioid requirements, reducing postoperative nausea and vomiting (PONV), and facilitating quicker bowel function recovery; (2) Due to the limited surgical trauma and the ease of controlling anesthesia depth, hemodynamic fluctuations are minimized. In addition, since ESD does not require the prolonged pneumoperitoneum necessary for laparoscopic surgery, it has less impact on respiratory function, thereby facilitating more stable intraoperative management and smoother extubation; and (3) The minimally invasive nature of ESD and short operative time reduce the incidence of postoperative delirium[2,3], offering distinct advantages for elderly patients, who are especially vulnerable to perioperative complications.

LIMITATIONS OF THE STUDY AND THE MISSING ANESTHETIC PERSPECTIVE

While this study successfully demonstrated the surgical and recovery benefits of ESD, it did not provide detailed discussion on anesthetic management, which is an essential component of ERAS. Nor did it include data on patient-centered outcomes such as postoperative pain, PONV, or satisfaction, which are closely tied to ERAS quality. This limitation might partly reflect the retrospective design.

For ESD, both general anesthesia and monitored anesthesia care are feasible. Current evidence suggests that, compared with monitored anesthesia care, general anesthesia significantly reduces perioperative complications such as perforation, bleeding, and cardiopulmonary events[4], without compromising complete resection rates[5]. Furthermore, the adjunctive use of dexmedetomidine during general anesthesia can lower postoperative pain scores, reduce the incidence of PONV, and shorten hospital stays[6]. These findings collectively suggest that general anesthesia remains the most appropriate anesthetic technique for ESD.

TOWARD ERAS PATHWAY FOR ENDOSCOPIC THERAPY

ESD surgery offers advantages such as minimal surgical trauma, fewer postoperative complications, and reduced hospital stays[1]. Consequently, patients scheduled for ESD treatment may have heightened expectations regarding perioperative comfort, which is precisely what ERAS strives for. It is worth emphasizing that existing ERAS protocols are primarily tailored to open or laparoscopic gastrectomy, while systematic ERAS pathways for endoscopic therapies remain underdeveloped. A limited number of studies have explored ERAS feasibility in ESD, reporting benefits such as shortened time to first flatus, reduced PONV, lower visual analogue scale pain scores, and decreased hospital stays[7-9].

In this context, anesthesiologists could play a pivotal role in shaping ERAS for ESD by: (1) Refining preoperative fasting and clear liquid intake guidelines; (2) Designing individualized multimodal analgesia; (3) Preventing PONV; (4) Implementing precise intraoperative fluid management; (5) Ensuring perioperative normothermia; (6) Applying protective ventilation strategies; and (7) Establishing contingency plans for intraoperative perforation. In addition, collaborating with gastroenterologists is essential to facilitate the implementation of ERAS pathways for patients.

CONCLUSION

The advancement of ESD represents not only a milestone in minimally invasive surgery but also an opportunity to align perioperative anesthetic management with ERAS principles. Future research, particularly randomized controlled trials, should prioritize perioperative optimization strategies, including anesthetic techniques, analgesic regimens, and recovery pathways to establish specialized “ESD-ERAS” protocols that maximize the synergy between minimally invasive approaches and ERAS.