Do we have enough evidence for expanding the indications of ESD for EGC?

Endoscopic submucosal dissection (ESD) is the most advanced and representative technique in the field of therapeutic endoscopy and has been used for the treatment of gastrointestinal neoplasms, including early gastric cancer. The major difference and advantage of ESD compared to existing endoscopic resection techniques, such as endoscopic mucosal resection (EMR) and polypectomy, are the width and depth of the resection. Newly developed cutting devices, distal attachable endoscopic accessories, and an advanced electrosurgical unit have helped to overcome the limitations of therapeutic endoscopy in terms of lesion size, location, presence of fibrotic scarring, and accompanying ulcers. As a result, the indications for ESD have been expanded from the classical indication for EMR and polypectomy, and there is now support for a further expansion of ESD indications. At present, the most critical factor to consider in the decision of whether to perform ESD is the probability of unexpected lymph node metastasis. The guidelines for ESD are continually being updated and debated. In this review, we discuss the strengths and weaknesses of the expanded guidelines, based on evidence found in the literature.