Endoscopic mucosal resection (EMR) is commonly accepted as a standard treatment for early gastric cancer (EGC) with low risk of lymph node metastasis because it is minimally invasive and has a good safety profile [1,2]. However conventional EMR nearly always results in piecemeal resection when lesions are larger than 20 mm in diameter, and even in smaller lesions R0 en bloc resection is often missed. Endoscopic submucosal dissection (ESD) is a new promising technique which can overcome this difficulty. In contrast to EMR, ESD allows en bloc resection of lesions larger than 20 mm in diameter. Advantages of the en bloc resection are an improvement in histopathological assessment of R0 resection and the lower risk of recurrence [3,4]. The Japanese Gastric Cancer Association (JGCA) defined guideline criteria for conventional EMR in the treatment of EGCs. EMR was judged adequate in elevated EGCs of less than 20 mm in diameter and in depressed EGCs of up to 10 mm without ulceration. Further restrictions were histology of differentiated adenocarcinoma, absence of submucosal invasion, and absence of lymphatic or vascular invasion [5]. However Gotoda et al. showed that these criteria might be too strict and too many patients might be unnecessarily treated by surgery [6]. Therefore based on an analysis of the risk of lymph node involvement in more than 5000 EGCs the expanded criteria were defined, as the risk of lymph node metastases in this group of patients was similar to that in the JGCA guideline group [6]. The expanded criteria are now widely accepted in Japan, and recently published studies show that there is no difference in outcome between treatment based on the guideline criteria and that based on the expanded criteria [7]. Expanded resection criteria are deBackground and study aims: Endoscopic submucosal dissection (ESD) is a promising technique for the resection of early gastric neoplasia. There are only a few data from the Western world to date. Methods: Over a 7-year-period, 104 gastric lesions were treated with ESD in a European referral center, of which 91 were included in this study. A total of 66 lesions were early gastric cancer (EGC) and 25 were adenomas. Of the EGCs, 11 lesions (16.7 %) fulfilled the guideline criteria (EGC-GC) and 55 lesions (83.3 %) fulfilled the expanded resection criteria (EGC-EC) of the Japanese guidelines for the treatment of gastric cancer. Results: ESD was technically possible in 85 lesions (93.4 %). In six lesions ESD was not possible due to non-lifting. En bloc resection rates for all lesions, ECGs-GC, ECGs-EC, and adenomas were 87.1 %, 100 %, 88.2 %, and 79.2 %, respectively. R0 en bloc resection rates were 74.1 %, 90 %, 68.6 %, and 79.2 %, respectively. Complications were: one

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