A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms

Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies

Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.

Collaboration between laparoscopic surgery and endoscopic resection: an evidence-based review

Developments in endoscopy and laparoscopy have made monumental changes to the way gastrointestinal diseases are being managed. Many diseases that were traditionally managed by open surgical resection could now be treated by endoscopy alone. However, there are still instances where endoscopic treatment alone is inadequate for disease control and laparoscopic surgery is required. In addition, the collaboration between laparoscopic surgery and endoscopic submucosal dissection or other endoscopic resectional techniques represents a new frontier for further research. The present manuscript aims to discuss the complementary role of laparoscopic surgery to endoscopic resection in the traditional context and also its future development.

Prospective, randomized comparison of a prototype endoscope with deflecting working channels versus a conventional double-channel endoscope for rectal endoscopic submucosal dissection in an established experimental simulation model (with video)

BACKGROUND

A prototype endoscope was designed to improve visualization and dissection of tissue with the use of 2 working channels with different deflections.

OBJECTIVE

To evaluate the efficacy and operability of a prototype endoscope in comparison with a conventional double-channel endoscope for rectal endoscopic submucosal dissection (ESD).

DESIGN

Randomized, prospective, controlled, ex vivo study.

SETTING

Academic medical center.

METHODS

A total of 80 standardized artificial lesions measuring 3 × 3 cm were created approximately 5 cm from the anal verge in fresh ex vivo porcine colorectal specimens. Two endoscopists each completed 20 cases with the prototype endoscope and 20 cases with the conventional endoscope.

MAIN OUTCOME MEASUREMENTS

An independent observer recorded procedure time, specimen size, en bloc resection, and perforation rate.

RESULTS

For the ESD novice, the mean submucosal dissection time (10.5 ± 3.8 vs 14.9 ± 7.3 minutes; P = .024) and total procedure time (18.1 ± 5.2 vs 23.6 ± 8.2 minutes; P = .015) were significantly shorter in the prototype group in comparison with the conventional group. For the ESD expert, there was no significant difference between the mean circumferential resection, submucosal dissection, and total procedure time (prototype group 14.2 ± 6.0 minutes, conventional group 14.2 ± 8.8 minutes; P = .992). The overall perforation and en bloc resection rates were not significantly different between groups.

LIMITATIONS

Ex vivo study.

CONCLUSION

In this ex vivo prospective comparison study, there was a technical advantage for the ESD novice with the prototype endoscope that resulted in a shorter procedure time, which was not observed for cases performed by the ESD expert.

Continued use of low-dose aspirin does not increase the risk of bleeding during or after endoscopic submucosal dissection for early gastric cancer

BACKGROUND

Although recent guidelines for endoscopic submucosal dissection (ESD) as treatment for early gastric cancer (EGC) recommend noninterruption of low-dose aspirin (LDA) perioperatively, this strategy is controversial. It was our practice to interrupt LDA therapy 5-7 days before to ESD until December 2010, when we instituted the new guidelines and performed ESD without interrupting LDA therapy. Our purpose in this study was to confirm the validity of noninterrupted use of LDA in patients undergoing ESD for EGC.

METHODS

We studied 78 consecutive patients with 94 EGCs who were routinely taking LDA and were treated by ESD at Hiroshima University Hospital between April 2005 and June 2012. The patients were of two groups: those in whom LDA was interrupted perioperatively (53 patients with 66 EGCs) and those in whom LDA was continued perioperatively (25 patients with 28 EGCs).

RESULTS

The complete resection rate was 92.4 % (61/66) in the LDA-interrupted group and 100 % (28/28) in the LDA-continued group. Incidences of poor bleeding control during the procedure and bleeding after procedure were 10.6 % (7/66) and 4.8 % (3/66), respectively, in the LDA-interrupted group and 7.1 % (2/28) and 3.6 % (1/28) in the LDA-continued group. Two patients in the interrupted-LDA group suffered cerebrovascular infarction before ESD, and 2 patients in this group suffered acute myocardial infarction after ESD.

CONCLUSIONS

Our data suggest that continued use of LDA does not increase the risk of bleeding during or after ESD for EGC and does decrease the risk of ischemic events.

Endoscopically assisted laparoscopic local resection of gastric tumor

Background

Minimally invasive procedures have been applied in treatment of gastric submucosal tumors. Currently, combined laparoscopic - endoscopic rendezvous resection (CLERR) emerges as a new technique which further reduces operative invasiveness.

Case presentation

A-57-year-old female patient presented with epigastric pain. She was submitted to gastroscopy, which revealed a tumor located at the angle of His. Biopsy specimens demonstrated a leiomyoma. The patient underwent endoscopically assisted laparoscopic resection of the tumor. The operative time was 45 minutes. Diagnosis of leiomyoma was confirmed by the final histopathological examination. The patient had an uneventful postoperative recovery and was discharged on the 2^nd postoperative day.

Conclusion

Combined laparoscopic and endoscopic rendezvous resection appears as a promising alternative minimally invasive technique. It offers easy recognition of the tumor, regardless of location, safe dissection, and full thickness resection with adequate margins as well as less operative time.

Preventing and controlling bleeding in gastric endoscopic submucosal dissection

Although techniques and instruments for endoscopic submucosal dissection (ESD) have improved, bleeding is still the most common complication. Minimizing the occurrence of bleeding is important because blood can interfere with subsequent procedures. Generally, ESD-related bleeding can be divided into intraprocedural and postprocedural bleedings. Postprocedural bleeding can be further classified into early post-ESD bleeding which occurs within 48 hours after ESD and late post-ESD bleeding which occurs later than 48 hours after ESD. A basic principle for avoiding intraprocedural bleeding is to watch for vessels and coagulate them before cutting. Several countertraction devices have been designed to minimize intraprocedural bleeding. Methods for reducing postprocedural bleeding include administration of proton-pump inhibitors or prophylactic coagulation after ESD. Medical adhesive spray such as n-butyl-2-cyanoacrylate is also an option for preventing postprocedural bleeding. Various endoscopic treatment modalities are used for both intraprocedural and postprocedural bleeding. However, hemoclipping is infrequently used during ESD because the clips interfere with subsequent resection. Bleeding that occurs as a result of ESD can usually be managed easily. Nonetheless, more effective ways to prevent bleeding, including reliable ESD techniques, must be developed.

Colon polypectomy: a review of routine and advanced techniques

The value of performing comprehensive screening colonoscopy with complete colon polypectomy is widely accepted. Colon cancer is a significant cause of worldwide mortality and prospective studies have proven that colonoscopic polypectomy reduces both the incidence and mortality related to this disease. Over the past few decades the array of instruments and techniques have greatly expanded to assist with the safe endoscopic removal of colon polyps. This article will review the published literature regarding efficacy and safety of standard polypectomy techniques such as snare polypectomy, electrocautery, and endoscopic mucosal resection along with newer techniques such as endoscopic submucosal dissection and combined laparoscopic techniques.

[Endoscopic submucosal dissection]

Endoscopic submucosal dissection (ESD) was developed in Japan but has now also become permanently established in various centers in Europe. ESD is an endoscopic en bloc mucosal resection technique for the treatment of early cancers with a diameter >1 cm and also superficial precancerous lesions, which could only be removed unsatisfactorily in several fragments or with uncertain lateral safety margins using previous loop excision procedures. Using ESD a lesion is excised after circular marking and generous submucosal injection with a safety margin of approximately 5 mm and subsequently resected at the level of the submucosa with a 1-3 mm short diathermic knife. ESD requires high technical skills in interventional endoscopy and is more time-consuming than snare resection techniques. However, numerous studies have shown a clear superiority for ESD with respect to the R0 resection rate and the local recurrence rate. The present article gives a current review of the use of ESD in the upper and lower gastrointestinal tract and demonstrates perspectives of the procedure.

Long-term outcome of early gastric cancer after endoscopic submucosal dissection: expanded indication is comparable to absolute indication

BACKGROUND

Endoscopic submucosal dissection has become widely used for early gastric cancer with an expanded indication, although there is no strong consensus. We aimed to compare the clinical and long-term oncological outcome after endoscopic submucosal dissection according to indication.

METHODS

Retrospective review of 1152 patients with 1175 lesions who had undergone endoscopic submucosal dissection for early gastric cancer at tertiary educational hospital in Korea, between March 2005 and November 2011. Of these, 366 and 565 lesions were included in the absolute and expanded indication groups, respectively.

RESULTS

En bloc resection rates were not significantly different between the absolute and expanded indication groups. The complete resection rate was higher in the absolute indication group versus the expanded indication group (94.8% vs. 89.9%, respectively; P=0.008). In the expanded indication group, complete resection rate was higher in the differentiated versus undifferentiated tumour subgroups (92.9% vs. 78.4%, respectively; P<0.001). Recurrence rates were 7.7% in the absolute indication group vs. 9.3% in the expanded indication group (P=0.524). Disease-free survival was not significantly different between the two indication groups (P=0.634).

CONCLUSIONS

Endoscopic submucosal dissection for early gastric cancer with expanded indication is a feasible approach to disease management. Periodic endoscopic follow-up is necessary to detect cancer recurrence.

Outcome of endoscopic submucosal dissection for gastric neoplasm in relationship to endoscopic classification of submucosal fibrosis

BACKGROUND

Whether submucosal fibrosis is related to ulceration and affects the outcome of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unknown. This study aimed to determine ESD outcome in relationship to degree of submucosal fibrosis of gastric epithelial neoplasms and to identify factors predictive of submucosal fibrosis.

METHODS

Eight hundred ninety-one patients with 1,027 gastric epithelial neoplasms were treated by ESD from April 2005 to January 2011. Complete en bloc resection and perforation rates in relationship to degree of submucosal fibrosis (F0, no fibrosis; F1; mild fibrosis; F2, severe fibrosis) were determined during ESD, as well as degree of concordance between endoscopically observed ulceration and pathologically determined ulceration and pathological fibrosis stained with Masson's trichrome.

RESULTS

The complete en bloc resection rate was significantly low and the perforation rate was high for F2 versus F0/F1 tumors. Ulceration, tumor size ≥30 mm, and depressed histological type were independent risk factors for severe (F2) fibrosis. No fibrosis (F0) was observed in 77% (732/951) of endoscopically negative ulceration cases, whereas fibrosis was observed in 100% (76/76) of endoscopically positive cases. Masson trichrome staining was weak in 97% (710/732) of F0, moderate in 85% (181/214) of F1, and strong in 100% (81/81) of F2 cases.

CONCLUSIONS

Histopathological type of submucosal fibrosis predicts outcome of ESD for EGC. Endoscopic indications of F2 submucosal fibrosis are ulceration, tumor ≥30 mm, and macroscopic depression.

Safety, efficacy, and long-term outcomes for endoscopic submucosal dissection of early esophagogastric junction cancer

BACKGROUND

Early esophagogastric junction (EGJ) cancer is currently being treated in the same way as early gastric cancer, by endoscopic submucosal dissection (ESD), but long-term outcomes are still unknown. Our aim was to retrospectively evaluate the safety and efficacy of ESD in treating early EGJ cancer and compare risk factors in curative and non-curative resection cases.

METHODS

Forty-four cases of early EGJ cancer, defined as a Siewert's type II tumor, in 44 patients with a mean age of 70.0 years and a male/female ratio of 90.9:9.1 % were treated by ESD between January 2004 and June 2010. There were 30 standard indication cases; the remaining 14 cases were expanded indication cases.

RESULTS

Mean resected specimen and tumor sizes were 35 and 17 mm, respectively, and median procedure time was 121 min, with no bleeding or perforation complications. All cases were resected en bloc with an 84.1 % curative resection rate (37/44). The curative resection rates in the standard and expanded indication cases were 90.0 % (27/30) and 71.4 % (10/14), respectively. There were no significant differences in tumor location, tumor morphology, tumor size, histology of biopsy specimens, or standard versus expanded indication cases with regard to risk factors for curative and non-curative resections. However, submucosal invasion, positive tumor margins, lymphovascular invasion, and some components of poorly differentiated adenocarcinomas in just the submucosal layer were significantly more common in the non-curative resection cases.

CONCLUSIONS

ESD was a safe, effective, and minimally invasive treatment for early EGJ cancer. For tumors without any submucosal invasion findings, therefore, ESD is an acceptable treatment option, in addition to also being suitable for diagnostic purposes in evaluating the need for surgery.

Endoscopic Therapy of Neoplasia Related to Barrett's Esophagus and Endoscopic Palliation of Esophageal Cancer

Background

Barrett's esophagus (BE) is the most important identifiable risk factor for the progression to esophageal adenocarcinoma.

Methods

This article reviews the current endoscopic therapies for BE with high-grade dysplasia and intramucosal cancer and briefly discusses the endoscopic palliation of advanced esophageal cancer.

Results

The diagnosis of low-grade or high-grade dysplasia (HGD) is based on several cytologic criteria that suggest neoplastic transformation of the columnar epithelium. HGD and carcinoma in situ are regarded as equivalent. The presence of dysplasia, particularly HGD, is also a risk factor for synchronous and metachronous adenocarcinoma. Dysplasia is a marker of adenocarcinoma and also has been shown to be the preinvasive lesion. Esophagectomy has been the conventional treatment for T1 esophageal cancer and, although debated, is an appropriate option in some patients with HGD due to the presence of occult cancer in over one-third of patients.

Conclusions

Endoscopic ablative modalities (eg, photodynamic therapy and cryoablation) and endoscopic resection techniques (eg, endoscopic mucosal resection) have demonstrated promising results. The significant morbidity and mortality of esophagectomy makes endoscopic treatment an attractive potential option.

Sedation methods can determine performance of endoscopic submucosal dissection in patients with gastric neoplasia

BACKGROUND

Although proper sedation is mandatory for endoscopic procedures such as endoscopic submucosal dissection (ESD), there is no research investigating the effects of sedation on ESD performance and complications. We aimed to evaluate the relationship among sedation methods, clinical outcomes, and complications after ESD for gastric neoplasia.

METHODS

We retrospectively reviewed clinical data of 1,367 patients with 1,485 lesions who had undergone ESD for gastric adenoma or early gastric cancer at our tertiary teaching hospital in Seoul, Korea, between January 2008 and May 2011. Of these, 1,035 lesions in 958 patients were included in the intermittent midazolam/propofol injection by endoscopists (IMIE) group, and 450 lesions in 409 patients were included in the continuous propofol infusion with opioid administration by anesthesiologists (CPIA) group.

RESULTS

En bloc resection and complete resection rates were higher in the CPIA group than in the IMIE group (CPIA vs. IMIE; en bloc resection, 99.8 and 95.0 %, P < 0.001; complete resection, 94.2 and 88.3 %, P < 0.001). Duration of procedure was shorter in the CPIA group than in the IMIE group (CPIA vs. IMIE; 48.2 ± 32.5 and 57.6 ± 41.3 min, P < 0.001). In multivariate analysis, sedation method was an independent factor associated with en bloc resection and complete resection. Additionally, sedation with CPIA was not a risk factor for bleeding (P = 0.403) or perforation (P = 0.474); however, aspiration pneumonia developed more frequently in patients sedated with CPIA (CPIA vs. IMIE, 4.4 and 1.5 %, P = 0.002).

CONCLUSIONS

Sedation with CPIA can improve ESD performance.

The incidence of "silent" free air and aspiration pneumonia detected by CT after gastric endoscopic submucosal dissection

BACKGROUND

Although endoscopic submucosal dissection (ESD) is feasible as a treatment for early gastric cancer, it requires great skill to perform and may place patients at increased risk of a number of complications, including perforation and aspiration pneumonia.

OBJECTIVE

To investigate the incidence of "silent" free air without endoscopic perforation and aspiration pneumonia detected by CT after ESD and risk factors for the development of these 2 conditions.

DESIGN

Prospective cohort study.

SETTING

Single academic center.

PATIENTS

This study involved 87 patients with a total of 91 malignancies.

INTERVENTION

All patients underwent chest and abdominal CT and blood biochemistry analysis before and 1 day after ESD.

MAIN OUTCOME MEASUREMENTS

The incidence of silent free air and aspiration pneumonia after ESD and the related risk factors.

RESULTS

Silent free air was identified in 37.3% of patients without perforation. Tumor location (the upper portion of the stomach), the presence of a damaged muscular layer during ESD, and procedure time, but not specimen size, were significantly associated with silent free air (P = .006, P = .04, P = .02, and P = .53, respectively). According to the receiver-operating characteristic analysis, the resulting cutoff value of the procedure time for silent free air was 105 minutes (67.7% sensitivity, 65.4% specificity). Only procedure time (≥ 105 minutes) was an independent predictor of silent free air development (odds ratio 3.23; 95% confidence interval, 1.21-8.64; P = .02). On the other hand, aspiration pneumonia was seen in 6.6% of patients. Silent free air and aspiration pneumonia did not affect hospitalization.

LIMITATIONS

Single center and small number of patients.

CONCLUSIONS

Silent free air is frequently observed after ESD, and longer procedure time (≥ 105 minutes) was an independent risk factor for silent free air. However, silent free air and aspiration pneumonia detected by CT are not associated with clinically significant complications.

Prospective randomized controlled trial to compare the effects of omeprazole and famotidine in preventing delayed bleeding and promoting ulcer healing after endoscopic submucosal dissection

BACKGROUND AND AIMS

Proton pump inhibitors (PPIs) are generally used to prevent delayed bleeding after endoscopic submucosal dissection (ESD) and to heal the artificial ulcers. However, it remains controversial whether PPIs or histamine-2 receptor antagonists (H(2) RAs) are more effective in preventing delayed bleeding after ESD. We prospectively compared the effects of omeprazole and famotidine in preventing delayed bleeding and promoting artificial ulcer healing after ESD.

METHODS

A total of 158 patients (155 early gastric cancers and three adenomas) were randomly assigned to the PPI group (omeprazole 20 mg/day) or H(2) RA group (famotidine 40 mg/day) in a prospective randomized controlled trial. The primary end point was the incidence of hematemesis, melena, and/or a decrease in hemoglobin level of 2 g/dL or more requiring endoscopic hemostatic treatment. ESD-induced ulcer healing and changes in ulcer size were also compared at 6 weeks after ESD as a secondary end point.

RESULTS

Of the 158 patients, two were excluded from analysis because they had been treated with a PPI before the present study. Accordingly, data from 77 PPI and 79 H(2) RA subjects were included for analysis. Delayed bleeding after ESD occurred in 6.5% of subjects (PPI group) and in 6.3% (H(2) RA group); there was no significant difference between the two groups. Likewise, the two groups were not significantly different with respect to ulcer stage or ulcer size reduction rate.

CONCLUSIONS

Proton pump inhibitors are not superior to H(2) RAs for the prevention of delayed bleeding or the healing of artificially induced ulcers after ESD.

[Endoscopic submucosal dissection in our practice -- new possibilities in the endoscopic treatment of neoplastic changes in the alimentary canal]

Endoscopic submucosal dissection is a promising new endoscopic technique for en block resection of early, superficial, flat, and laterally spreading gastrointestinal neoplasms. The primary aims of this prospective study were to summarize the first Hungarian experience with endoscopic submucosal dissection, and to compare the experimental in vivo procedures in pigs with the human application of this technique in two academic centers.

METHODS

The ex vivo Erlangen pig model was used until initial competence was achieved. Thereafter 15 endoscopic submucosal dissection procedures were performed in up to 5 sessions in living pigs under general anesthesia. After submucosal injection with saline Fujinone ball tip, a Flush knife was used with a transparent hood for circumferential incision and submucosal dissection. The following variables were analyzed: specimen size, complete and en bloc resection rate, total duration of the procedure, and complications. Furthermore, between 2009 and 2012, 14 endoscopic submucosal dissections were carried out in humans; 1 duodenal, 3 gastric and 10 colorectal interventions were performed due to large laterally spreading intramucosal neoplasms. The specimen size, en bloc resection rate, total duration of the procedure and complications were next analyzed.

RESULTS

87% complete resection rate, 29.4 ± 19.5 cm2 specimen size and 136.2 ± 26.8 min of procedure duration were achieved in the live pig models. Nontransmural damages of the muscular layer occurred in 3/15 (20%) cases which were successfully closed with hemoclips, except in one pig that died due to fatal esophageal perforation. All bleedings were easily managed with hot biopsy forceps coagulation and hemoclips without hemodynamic instability. In humans, endoscopic submucosal dissection was accomplished with an 11/14 (79%) en block resection rate, with average resected specimen size of 11.56 ± 4.9 cm2 and with 157 ± 55 min of operating time. Two cases of bleeding and 2 cases of perforation occurred (14%), all of which were managed endoscopically. After 1.5 year of average follow up, local recurrence occurred in one case only. In addition, due to the 3 incomplete resections and unsuccessful endoscopic submucosal dissection, surgical intervention was required in 4 cases altogether.

CONCLUSIONS

This study demonstrates the first Hungarian experience with endoscopic submucosal dissection. Training in live pig models could help endoscopists to overcome the learning curve and minimize the risk of complications before starting the procedure in humans. Reduction in the resection time and low risk of complications, especially bleeding, could be achieved by the application of a flush knife.

A water-jet videoendoscope may reduce operation time of endoscopic submucosal dissection for early gastric cancer

BACKGROUND

One of the problems with endoscopic submucosal dissection (ESD) for early gastric cancer is that it prolongs procedure time considerably.

AIM

The purpose of this study was to investigate whether a videoendoscope with water-jet function shortened the time of ESD for early gastric cancer.

METHODS

A total of 82 early gastric cancers that were intramucosal, differentiated-type adenocarcinoma ≤2 cm, without ulcer or scar, in 75 consecutive patients were investigated. Three supervised resident endoscopists participated as operators. After stratification by the operator and tumor location, the lesions were randomly assigned to the water-jet videoendoscope or a conventional videoendoscope groups. An insulated tipped knife was used for the ESD procedure. Total operation time was evaluated as a primary endpoint.

RESULTS

The median (25-75th percentile) total operation time for the water-jet videoendoscope group was 51 (33-87) minutes, which was shorter than the 62 (43-88) minutes for the conventional videoendoscope, but it did not reach significance (P = 0.201). Multivariate analysis revealed that the water-jet videoendoscope (OR 3.0, P = 0.046), tumor size ≤14 mm (OR 3.2, P = 0.040) and antral tumor (OR 4.5, P = 0.046) were significantly associated with short (≤60 min) operation time.

CONCLUSIONS

The water-jet videoendoscope may reduce operation time of ESD for early gastric cancer, compared with conventional videoendoscope. A large-scale multicenter trial is warranted to clarify the efficacy of the water-jet videoendoscope for gastric ESD.

Diagnosis of depressed-type early gastric cancer using small-caliber endoscopy with flexible spectral imaging color enhancement

BACKGROUND AND AIM

Small-caliber endoscopy has lower resolution than normal-caliber endoscopy, limiting its use in routine outpatient practice. Flexible spectral imaging color enhancement (FICE) strengthens the color contrast of depressed-type early gastric cancer without magnification. The aim of the present study was to evaluate the detection of depressed-type early gastric cancer using small-caliber endoscopy with the FICE system.

METHODS

Eighty-two patients diagnosed with depressed-type early gastric cancer by standard endoscopy and biopsy were evaluated by small-caliber endoscopy. FICE images and conventional images were compared. Color differences in all 82 lesions were measured between malignant lesions and the surrounding mucosa using the Commission Internationale de L'Eclairage (CIE) 1976 color space.

RESULTS

Most cancers were readily detected as reddish lesions on FICE images. Lines of demarcation between the malignant lesion and the surrounding mucosa were easily identified with FICE images, as such cancers could be clearly distinguished from the surrounding atrophic mucosa. Greater median color differences between malignant lesions and the surrounding mucosa were present in FICE images compared with conventional images, resulting in images with better contrast (27.2 vs 18.7, P<0.0001).

CONCLUSIONS

Small-caliber endoscopy with the FICE system provides better color contrast of depressed-type early gastric cancers than conventional small-caliber endoscopy, and the FICE system may facilitate the diagnosis of this type of cancer as a new endoscopic modality.

Routine follow-up biopsies after complete endoscopic resection for early gastric cancer may be unnecessary

Purpose

Local recurrence, due to residual tumor, may occur after endoscopic resection for early gastric cancer. The aims of this study are to evaluate the predictive factors for local recurrence, and suggest an appropriate follow-up biopsy strategy.

Materials and Methods

We retrospectively reviewed 396 early gastric cancers from 372 consecutive patients, who underwent endoscopic resection between January 2002 and April 2008. Cumulative recurrence rates were determined by the Kaplan-Meier method, and Cox proportional hazard analysis was used to determine the risk factors for local recurrence.

Results

Local recurrence at the endoscopic resection site was found in 17 cases, among the total 396 lesions, during a median follow-up period of 48 months. The 5-year cumulative local recurrence rate was 4.8%. Multivariate analyses determined that tumor involvement at the lateral resection margin [hazard ratio: 35.9; P<0.001], uncheckable lateral resection margin [hazard ratio: 16.8; P<0.001], uncheckable or involved deep resection margin [hazard ratio: 3.76; P=0.047], and piecemeal resection [hazard ratio: 3.95; P=0.007] were associated with local recurrence. If a lesion was positive for any of these risk factors, the 5-year cumulative recurrence rate was 27.0%, while local recurrence was not found in any lesion that lacked these risk factors. Most episodes of recurrence were found during the first or second follow-up endoscopic biopsy at the ulcer scar.

Conclusions

Routine follow-up biopsies at the endoscopic resection site might be unnecessary in cases where an early gastric cancer lesion was endoscopically resected en bloc with tumor-free lateral and deep margins.

Endoscopic submucosal dissection of early gastric neoplasia with a water jet-assisted knife: a Western, single-center experience

BACKGROUND

Endoscopic submucosal dissection (ESD) of early gastric neoplasia has not yet been established in Western countries because of a lack of data and the difficult, time-consuming, and hazardous nature of the method. Some of the technical limitations may be overcome by use of a water jet-assisted knife, which allows a combination of a high-pressure water jet and electrosurgical interventions.

OBJECTIVE

To evaluate the efficacy and safety of water jet-assisted ESD (WESD) with a water jet-assisted knife in selected patients with early gastric neoplasia.

DESIGN

Single-center, prospective study.

PATIENTS

This study involved 29 consecutive patients (13 female; median age 61 years; age range 35-93 years) with early gastric neoplasia that met the expanded criteria of the Japanese Gastric Cancer Association. Histology of biopsies had shown gastric adenocarcinoma in 21 cases, adenoma in 8 case, and suspicion of a GI stromal tumor in 1 case. The median maximal diameter of the lesions was 20 mm (range 10-40 mm).

INTERVENTION

All procedures were done with patients under sedation with propofol. The water jet-assisted knife was used for setting coagulation markers around the neoplastic lesions, then for circumferential incision and dissection in combination with repeated submucosal injection of saline solution with a water jet system. Bleeding was treated with diathermia by use of the water jet-assisted knife or hemostatic forceps in case of failure or larger vessels. Clips were used for closure of perforations.

MAIN OUTCOME MEASUREMENTS

Complete resection of neoplasia, procedure time, complication and recurrence rates.

RESULTS

According to endoscopic criteria, complete resection of the targeted area could be achieved in all cases, with an en bloc resection rate of 90%. The median procedure duration was 74 minutes (range 15-402 minutes). Exchange of the device was needed in only 10 cases because of severe bleeding from larger vessels, which could be managed by use of hemostatic forceps. The 30-day morbidity rate was 4 of 30 (13.8%) because of postprocedure pain in 3 cases and delayed bleeding in 1 case. A 93-year-old patient died the night after WESD without evidence of a procedure-related complication. Histology of the resected specimens showed adenocarcinoma in 20 cases, adenoma in 7, no neoplasia in 2, and a plasmacytoma in 1. Complete resection (R0) was histologically confirmed in 18 of 28 patients (64.3%) with resected neoplastic specimens. A horizontal or vertical neoplasia-free margin could not be confirmed in 9 cases and 1 case, respectively. Complete local remission of neoplasia was achieved in 25 of 28 patients (89.3%) who were followed over a median period of 22 months (range 6-44 months). In 1 patient, a metachronous gastric adenocarcinoma was identified 54 weeks after initial WESD.

LIMITATIONS

Noncontrolled study with a limited number of patients.

CONCLUSION

The use of a water jet-assisted knife simplifies ESD because exchange of devices is rarely needed. WESD promises to be effective and safe. The study demonstrates that the high rates of en bloc resection of early gastric neoplasia reported in Asia can be reproduced in Western referral centers. However, histology may not always confirm complete resection of horizontal tumor margins. In spite of the unfavorable histology results, the high rate of complete local remission of neoplasia promises that surgical treatment of early gastric neoplasia can be avoided in the majority of cases.

Additional gastrectomy after endoscopic submucosal dissection for early gastric cancer patients with comorbidities

Purpose. We investigated the clinicopathologic features of early gastric cancer (EGC) patients who have undergone additional gastrectomy after endoscopic submucosal dissection (ESD) because of their comorbidities. Methods. Eighteen (7.1%) of 252 GC patients were gastrectomized after prior ESD. Reasons for further surgery, preoperative and postoperative problems, and the clinical outcome were determined. Results. The 18 patients had submucosal EGC and several co-morbidities. Other primary cancers were observed in 8 (44.4%). Histories of major abdominal operations were observed in 6 (33.3%). Fourteen patients (77.8%) hoped for endoscopic treatment. Due to additional gastrectomy, residual cancer was suspected in 10, and node metastasis was suspected in 11. A cancer remnant was histologically observed in one. Node metastasis was detected in 3 (16.7%). Small EGC was newly detected in 4. Consequently, additional gastrectomy was necessary for the one third. No patient showed GC recurrence. However, 9 (50%) had new diseases, and 4 (22.2%) died of other diseases. The overall survival after surgery in these patients with additional gastrectomy was poorer than those with routine gastrectomy for submucosal EGC (P = 0.0087). Conclusions. Additional gastrectomy was safely performed in EGC patients with co-morbidities. However, some issues, including presence of node metastasis and other death after surgery, remain.

How to teach and learn endoscopic submucosal dissection for upper gastrointestinal neoplasm in Japan

BACKGROUND

Endoscopic submucosal dissection (ESD) is an innovative and promising procedure. However, ESD experience is mostly limited to Japan and a few countries in Asia. An appropriate training system should be proposed from Japan to promote a permeation of ESD technique. We conducted questionnaire survey to representative Japanese experts to reveal their training method of ESD for upper gastrointestinal neoplasm.

MATERIALS AND METHODS

We sent the questionnaire on gastric and esophageal ESD to 9 Japanese experts in ESD. The questionnaire results were discussed in a session of Endoscopic Forum Japan 2011 held in Tokyo.

RESULTS

The inception criteria consisted of two main elements, diagnostic ability and primary endoscopy technique of preceptees. Preceptees should observe and attend as many ESD cases as possible. Most of the experts recommend training with isolated or live animal stomach or esophagus. Lesion in the distal stomach is the most suitable for the first real ESD by a preceptee. Being proficient in a gastric ESD is needed before starting esophageal ESD. Preceptor should have significantly high level of diagnostic ability and proficient ESD techniques in the colorectum as well as the stomach and esophagus.

CONCLUSION

The present questionnaire survey seems to reveal basic elements required for ESD training program. We believe that this is also helpful in other countries where ESD would be initiated and penetrated safely and properly.

A decade in gastric cancer curative surgery: Evidence of progress (1999-2009)

To investigate the progress in evidence-based surgical treatment of non-metastatic gastric cancer, we reviewed the last ten years’ literature. The data used in this review were identified by searches made on MEDLINE, Current Contents, PubMed, and other references taken from relevant original articles (on prospective and retrospective studies) concerning gastric cancer surgery. Only papers published in English between January 1999 and December 2009 were selected. Data from ongoing studies were obtained in December 2009, from the trials registry of the United States National Institutes of Health (http://www.clinicaltrial.gov). The citations list was presented according to evidence based relevance (i.e., randomized controlled trials, prospective studies, retrospective series). In the last ten years, many challenges have been faced relating to the extension of gastric resection and nodal dissection as well as surgical timing, but we found only limited evidence, regardless of latitude of study. The ongoing phase-III trials may provide answers that will be valid for the coming decades, and which may bring definitive answers for the currently unresolved questions.

Clinical validity of endoscopic submucosal dissection for submucosal invasive gastric cancer: a single-center study

BACKGROUND

The 2010 Japanese Gastric Cancer Association guidelines for the treatment of submucosal invasive gastric cancer (SM-GC) specify size 30 mm or less, differentiated-dominant histology, lack of vessel involvement, and submucosal invasion of less than 500 μm (SM1) as expanded criteria for curative endoscopic resection. Our purpose in this study was to confirm the validity of the expanded indications for curative endoscopic submucosal dissection (ESD) of SM-GC.

METHODS

The study subjects were 173 patients with SM-GC resected by ESD at Hiroshima University Hospital between April 2002 and September 2010, including 99 patients for whom 3-plus years' follow-up information was available. Post-ESD outcomes were compared between cases of SM1-GC that met the expanded ESD criteria, those that did not, and SM2-GC cases.

RESULTS

Complete resection was achieved for 93.2% of the SM1-GCs that met the expanded criteria. There was neither metastasis to lymph nodes or other organs nor local recurrence among the SM1-GCs. Disease-specific survival did not differ significantly between patients that were simply followed up after ESD and those that were treated by additional surgical resection.

CONCLUSIONS

Our outcome data support the clinical validity of ESD without additional surgical resection for SM1-GCs that meet the expanded criteria.

Efficacy of endoscopic mucosal resection with circumferential incision for patients with large colorectal tumors

BACKGROUND & AIMS

Treatment of large colorectal neoplasms (>20 mm in diameter) by conventional endoscopic mucosal resection (EMR) often results in piecemeal resection that requires further intervention. We evaluated the efficacy of EMR with circumferential incision (CEMR).

METHODS

From March 2008-July 2009, we resected 24 large colorectal neoplasms measuring 20-40 mm in diameter by using the CEMR technique. CEMR was performed by using a ball-tip bipolar needle knife with a snaring technique. After the injection of glycerol into the submucosal layer, a circumferential incision was made, and the neoplasm was resected by snaring. All lesions that showed a noninvasive pattern were diagnosed by magnifying chromoendoscopy as adenomas or intramucosal or submucosal superficial cancers. The number of en bloc resections and complications and the overall procedure time were determined.

RESULTS

The proportions of en bloc and 2-piece resections by CEMR were 67% (16/24) and 17% (4/24), respectively. The median (interquartile range) time for CEMR completion was 40 minutes (30-63 minutes). No postsurgery complications occurred in any patient.

CONCLUSIONS

CEMR might provide acceptable clinical outcomes for patients with large colorectal neoplasms. It results in a low incidence of incomplete treatments and low risk of complications.

Clinical features and predictive factors of coagulation syndrome after endoscopic submucosal dissection for early gastric neoplasm

BACKGROUND

Various endoscopic submucosal dissection (ESD)-related complications, such as perforation or bleeding, occur frequently. However, the clinical course of coagulation syndrome (CS) after ESD is not known. The aim of this study was to clarify the clinical outcomes and predictive factors of CS after ESD for early gastric lesions.

METHODS

ESD procedures were performed in the typical sequence (marking, incision, and submucosal dissection). Four hundred and ninety-five patients with early gastric neoplasms were classified into two groups based on their clinical course after ESD: one group with post-ESD CS and the other with a normal clinical course. The clinical outcomes of the CS group were analyzed, and various clinical and pathological factors related to post-ESD CS were investigated using univariate and multivariate analyses.

RESULTS

Coagulation syndrome occurred after ESD in 35 patients. In the CS group, the median period of inflammatory symptoms was 23.7 ± 12.0 h, and no blood cultures showed bacteremia. Multivariate analysis demonstrated that a tumor size of more than 1.5 cm [odds ratio (OR) 5.99, P < 0.001], tumor location in the middle third of the stomach (OR 2.84, P = 0.005), and a procedural time longer than 45 min (OR 2.71, P = 0.033) were independent risk factors for this complication. All patients with CS presented with a favorable outcome, irrespective of antibiotic treatment.

CONCLUSIONS

This study suggests that CS occurs with an incidence of 7.1% after ESD for gastric lesions, and the factors associated with post-ESD CS include tumor size and location, and procedural duration.

Phlegmonous gastritis after endoscopic submucosal dissection for early gastric cancer

A 74-year-old man with diabetic nephropathy developed epigastric pain and high fever after endoscopic submucosal dissection (ESD) for early gastric cancer. Gastroscopy, endoscopic ultrasonography and computed tomography showed ulceration with a purulent lake, thickened entire gastric mucosal layers suggesting focal abscess formation, leading to the diagnosis of phlegmonous gastritis. He underwent total gastrectomy as an emergency. Histological findings of the resected specimen showed severe inflammatory cell infiltration and multiple focal abscess formation spreading to the entire gastric wall. In patients with poorer general conditions, phlegmonous gastritis should be considered as a serious complication after ESD, indicating a requirement of antibiotic prophylaxis.

Gastric adenocarcinoma surgery and adjuvant therapy

Gastric adenocarcinoma is one of the most common causes of death worldwide. Surgical resection remains the mainstay of therapy, offering the only chance for complete cure. Resection is based on the principles of obtaining adequate margins, with the extent of lymphadenectomy remaining controversial. Neoadjuvant and adjuvant therapies are used to reduce local recurrence and improve long-term survival. This article reviews the literature and provides a summary of surgical management options and neoadjuvant/adjuvant therapies for gastric adenocarcinoma.

Sodium alginate as an ideal submucosal injection material for endoscopic submucosal resection: preliminary experimental and clinical study

BACKGROUND

Sodium alginate is used clinically in the treatment of peptic ulcer disease. Because of its viscosity, sodium alginate could possibly become a new submucosal injection material for use in endoscopic resection.

OBJECTIVE

We evaluated the feasibility of endoscopic submucosal dissection (ESD) using sodium alginate.

SETTING AND INTERVENTIONS

The lesion-lifting properties of sodium alginate were examined in porcine stomachs and were compared with those of normal saline solution and sodium hyaluronate solution. After confirming the proper concentration of sodium alginate, ESD using sodium alginate was performed in 11 patients with gastric mucosal cancer or adenoma.

MAIN OUTCOME MEASUREMENT

The lesion-lifting properties of sodium alginate and clinical outcomes were assessed.

RESULTS

The thickness of the submucosal elevation created by 3% sodium alginate in porcine stomach was equivalent to that of sodium hyaluronate. ESD using sodium alginate was completed successfully in all patients without adverse effects except in 1 patient in whom transient shrinkage of the gastric wall disappeared spontaneously after approximately 30 minutes. The mean tumor size was 15.3 mm. En bloc resection and a negative resection margin were obtained in all. Histopathologic examination revealed that all tumors were confined to the mucosal layer except for 1 that was confined to the submucosal layer without lymphovascular invasion, and there were no adverse effects such as tissue damage. No patient required additional treatment, and none showed recurrence during a median follow-up period of 28 months.

LIMITATIONS

Small sample size.

CONCLUSION

This preliminary study suggests that sodium alginate might be a novel, safe submucosal injection material for use in endoscopic resection. Further investigation of the properties of sodium alginate is warranted.

Risk factors for bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm

BACKGROUND

Although endoscopic submucosal dissection (ESD) is standard therapy in Japan for gastric epithelial neoplasm, the complication rate is unsatisfactory, with postoperative bleeding as the major complication. The aim of the present study was to determine risk factors for post-ESD bleeding in patients with gastric epithelial neoplasm.

PATIENTS AND METHODS

The study included 764 patients in whom 924 gastric epithelial neoplasms were resected endoscopically between June 2005 and December 2009: the period during which preventative coagulation for all exposed vessels on the artificial ulcer with hemostatic forceps upon completion of ESD was performed routinely. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors.

RESULTS

The post-ESD bleeding rate was 3.0%. Dialysis (vs no dialysis, P = 0.034), operation time ≥75 min (vs <75 min, P = 0.012) and poor control of bleeding during ESD (vs good control, P = 0.014) were significantly related to post-ESD bleeding. Poor control of bleeding during ESD (vs good control; P = 0.04) and operation time ≥75 min (vs <75 min; P = 0.012) were significantly related to bleeding after second-look endoscopy.

CONCLUSIONS

Patients at high risk for post-ESD bleeding in gastric epithelial neoplasm were those undergoing dialysis, those in whom operation time was ≥75 min, and those in whom bleeding during ESD was poorly controlled. The latter two are risk factors for bleeding even after second-look endoscopy.

Endoscopic submucosal dissection with a flexible Maryland dissector: randomized comparison of mesna and saline solution for submucosal injection (with videos)

BACKGROUND

Endoscopic submucosal dissection (ESD) is increasingly used for en bloc removal of GI lesions. Current ESD techniques have limitations including long procedure times, technical difficulty, and complications.

OBJECTIVE

To compare mesna with saline solution for ESD.

DESIGN

Blinded, randomized, controlled, porcine study in live animals.

SETTING

Animal laboratory.

INTERVENTION

Twelve gastric lesions were marked by using electrocautery. After submucosal injection, a circumferential mucosal incision was created, and ESD was performed by using a flexible Maryland dissector. Half of the ESDs were performed with submucosal injection of mesna.

MAIN OUTCOME MEASUREMENTS

Primary outcome was the time to dissect the submucosal plane. Secondary outcomes were total ESD time, specimen size, and procedure related complications.

RESULTS

The average (± SD) time for dissecting the submucosal plane was 15 minutes (range 10-22 ± 4.8 min) in the group with submucosal mesna injection and 16 minutes (range 8-29 ± 8.3 min) in the control group (P = 1.0). Complete en bloc resection including all of the electrocautery markings was achieved in all cases. Injection of mesna did not provide any benefit over saline solution in terms of overall ESD time (24 ± 7.3 min vs 28 ± 11 min; P = .42). There were no perforations. Four hemorrhages requiring intervention were encountered during the procedures in the control group, compared with no bleeding in the mesna group (P = .09).

LIMITATIONS

Animal model, limited sample size.

CONCLUSION

Submucosal mesna injection did not affect procedure times but was associated with a trend toward a lower incidence of intraprocedural bleeding.

Endoscopic submucosal dissection for submucosal invasive gastric cancer and curability criteria

AIMS

The aims of the present study were to evaluate the feasibility of endoscopic submucosal dissection (ESD) as curative treatment for node-negative submucosal invasive early gastric cancer (EGC) and to consider further expansion of the curability criteria for submucosal invasive EGC.

METHODS

A total of 977 EGC in 855 patients treated by ESD were enrolled. They were divided into intramucosal cancer (M); minimally submucosal invasive cancer (<500µm from the muscularis mucosa) (SM1); and deeper submucosal invasive cancer (>500µm from the muscularis mucosa) (SM2). The technical feasibility of ESD for SM1 and M were compared, and the clinical prognosis of SM1 was evaluated. Furthermore, the volume of carcinoma invading to the submucosal layer, which we called the SM volume index, was calculated virtually to analyze its correlation with lymphatic-vascular invasion.

RESULTS

There were no statistical differences in technical outcomes and complications between M and SM1. Curative resection rates were significantly better in M than in SM1 (M, 92.6%; SM1, 63.8%). No local recurrences and distant metastases were found in 48 SM1 patients declared to have undergone curative resections. Most cases (72.0%) with successful ESD but non-curative resection exceeded 30mm in maximum size, and no local recurrences and metastases were found in these patients. The SM volume index of these cases was comparatively small.

CONCLUSION

The technical and theoretical validity of ESD for SM1 was validated. The possibility of further expansion of the curability criteria for submucosal invasive cancers was suggested by the evaluation of the SM volume index.

Evaluation of a new multitasking platform for endoscopic full-thickness resection

BACKGROUND

The advent of natural orifice transluminal endoscopic surgery (NOTES) has accelerated the development of new technology in the field of GI endoscopy. Various suturing devices or multitasking platforms are expected to be valuable for endoluminal surgery as well as for NOTES.

OBJECTIVE

To evaluate a new multitasking platform in performing endoscopic full-thickness resection (EFTR).

DESIGN

Bench-top comparison study.

SETTING

Research laboratory study of 10 ex vivo porcine models.

INTERVENTION

Ten EFTRs (5 with a double-channel endoscope vs 5 with a new multitasking platform) assisted with percutaneous gastric lifting. Each group was given the task of resecting a full-thickness specimen of the gastric wall including a pseudolesion 10 mm in diameter with an effective margin.

MAIN OUTCOME MEASUREMENTS

Outcome measurements included time to perform the procedure, accuracy of the resection, and efficiency for the task. Accuracy was assessed according to variability of the surgical margin and misalignment between the mucosal layer and the seromuscular layer. Efficiency was assessed according to the duty ratio, which is the percentage of time spent for the main purposes compared with the total procedure time.

RESULTS

Mean diameter of the specimen was not significantly different between the groups. All other assessment items were significantly superior in group B to those in group A (P < .05).

LIMITATIONS

Ex vivo animal model study.

CONCLUSION

We were able to perform EFTR procedures precisely and effectively by using a new multitasking platform compared with use of a conventional endoscope in a porcine model. A multitasking platform developed for NOTES procedures would be useful for advanced endoluminal surgery such as endoscopic submucosal dissection or EFTR as well as NOTES.

Predicting the absence of lymph node metastasis of submucosal invasive gastric cancer: expansion of the criteria for curative endoscopic resection

OBJECTIVE

The conditions upon which endoscopic resection (ER) can be considered curative for submucosal invasive gastric cancer remain controversial; thus, unnecessary surgery is sometimes performed after ER. Our purpose is to evaluate the significance of several clinicopathological factors for predicting the absence of lymph node (LN) metastasis of submucosal invasive gastric cancer and thus determining cases in which ER can be considered curative.

PATIENTS AND METHODS

The study group comprised 220 patients with submucosal invasive gastric cancer that was resected surgically or endoscopically. Patients treated by ER underwent additional surgical resection. The presence of LN metastasis was evaluated in all patients, retrospectively.

RESULTS

LN metastasis was detected in 37 (16.8%) of the 220 patients. Independent risk factors for LN metastasis were width of submucosal invasion>6000 μm, lymphatic involvement, undifferentiated type at the deepest invasive portion, depth of submucosal invasion>1000 μm, and tumor diameter>30 mm. The group of 36 patients with submucosal invasion to a depth of ≤1000 μm, tumor diameter ≤30 mm, differentiated type as the dominant histologic type, and absence of vessel involvement was entirely free of LN metastasis (95% confidence interval, 0-8.0%).

CONCLUSIONS

Taken together, the five independent risk factors may allow expansion of the criteria for determining whether ER for submucosal invasive gastric cancer has been curative.

Endoscopic submucosal dissection (ESD) using the needle knife: its superiority to ESD using the insulation-tipped diathermic knife in physicians intending to master ESD

In the absence of a supervisor, we conducted endoscopic submucosal dissection (ESD) procedures using the needle-knife and insulation-tipped (IT) diathermic knives for 516 gastric neoplasms in 443 Japanese patients with the diseases. No significant difference was found between IT knife ESD and needle-knife ESD in en bloc resection rates with tumor-free margins (89.8% and 92.9% for IT knife ESD and needle-knife ESD, respectively) and perforation rates (2.2% and 4.6%, respectively). However, the mean procedure time was significantly (P<0.05) shorter in IT knife ESD than in needle-knife ESD (74 and 88 min, respectively) and reached a plateau after accumulating 120 cases of ESD in both procedures. We required a less number of ESD cases before being proficient at needle-knife ESD than in IT knife ESD (30 cases and 60 cases, respectively). Needle-knife ESD is recommended for physicians who intend to master ESD hereafter.

Predictive factors for local recurrence after endoscopic resection for early gastric cancer: long-term clinical outcome in a single-center experience

BACKGROUND

Endoscopic resection is widely accepted as the primary treatment for early gastric cancer (EGC) without lymph node metastasis. A new and refined technique, endoscopic submucosal dissection (ESD), may prove to be more effective; however, incomplete resection and local recurrence present ongoing concerns. We sought to determine the clinicopathological features associated with local recurrence in patients with EGC following endoscopic resection.

METHODS

We enrolled in this study 239 EGC patients treated by endoscopic resection between January 2002 and January 2008.

RESULTS

Fifty EGC lesions were treated by conventional endoscopic mucosal resection (EMR group) and 189 EGC lesions were treated by ESD (ESD group). During the follow-up period (mean = 30.3 months), the rates for en bloc resection and complete resection (defined as en bloc resection with negative resection margin) were 64% (32/50) and 60% (30/50), respectively, in the EMR group, and 86.8% (164/189) and 79.9% (151/189), respectively, in the ESD group. We observed seven local recurrences in the ESD group, though only one with complete resection by ESD had a local recurrence. The EMR group showed a significantly higher recurrence rate than did the ESD group (18% vs. 3.7%, respectively, p < 0.001). Incomplete resection significantly increased local recurrence risk, and larger tumor size and use of EMR increased the risk for incomplete resection. Most lesions (3/4) treated with additional argon plasma coagulation for an initial recurrence had recurred again.

CONCLUSIONS

Despite the potential advantages in treating EGC with ESD, a risk for local recurrence remains. All patients treated with EMR, even with curative resection, and those with incomplete resection after ESD require conscientious surveillance for local recurrence. Furthermore, a large prospective study will be required to determine the best treatment modality for local recurrence.

Outcomes of endoscopic submucosal dissection versus endoscopic mucosal resection in management of superficial squamous esophageal neoplasms outside Japan

GOALS

This study aims to evaluate the outcomes of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) in management of superficial squamous esophageal neoplasms.

BACKGROUND

Endoscopic resection is a potential alternative in treatment of superficial squamous esophageal neoplasms. However, there have been limited reports comparing the outcomes of ESD versus EMR in the treatment of these lesions outside Japan.

STUDY

A retrospective analysis of all patients with high-grade superficial neoplasms (moderate to severe dysplasia and noninvasive carcinoma) or intramucosal carcinoma resected endoscopically between January 2002 and December 2007 was carried out. Clinical and pathologic outcomes were compared.

RESULTS

ESD was done in 22 lesions (18 patients) and cap-EMR in 13 lesions (10 patients). ESD allowed resection of larger lesions indicated by a significantly longer endoscopic length (P=0.015), larger specimen size (P<0.001), and more lesions extending for more than half the circumference of the esophagus (P=0.005) when compared with cap-EMR. ESD also achieved with a higher en bloc resection rate (P=0.052) and lower piecemeal resection rate (P=0.015). Procedure-related morbidities were not significantly different (P=1.0). There was no procedure-related mortality in the entire series.

CONCLUSIONS

ESD allows en bloc resection of larger mucosal lesions of the esophagus, earlier not possible by cap-EMR. This is achievable without significantly increasing the risks to the patient even in low-volume centers outside Japan. Whether ESD decreases the local recurrence and improves survival when compared with cap-EMR will require further long-term follow-up studies.

Recent knowledge of the relationship between Helicobacter pylori and gastric cancer and recent progress of gastroendoscopic diagnosis and treatment for gastric cancer

Gastric cancer is a multi-step process and multi-factorial disease. However, Helicobacter pylori plays the most important role in gastric carcinogenesis because most gastric cancers including both intestinal type and diffuse type arise from mucosa infected by H. pylori. The relationship between H. pylori infection and gastric cancer has been proved in epidemiological studies, animal experiments with Mongolian gerbils, and clinical prospective studies. Significant preventive effect of H. pylori eradication was reported in Japanese randomized study for secondary gastric cancer after endoscopic resection of primary gastric cancer and meta-analysis of randomized studies. The Japanese Society for Helicobacter Research has published a guideline recommending that H. pylori infection should be treated by eradication therapy to suppress the incidence of gastric cancer. The development of endoscopic technology has advanced the diagnosis and treatment of gastric cancer. In the diagnosis of gastric cancer, image enhancement endoscopy including magnifying observation with narrow-band imaging system and microscopic magnifying observation opens the possibility of optical biopsy. Endoscopic resection for early stage of gastric cancer has been established as proper treatment of early gastric cancer. Recently endoscopic submucosal dissection had made en bloc resection possible for mucosal cancers >2 cm in diameter. Because of endoscopic submucosal dissection, endoscopic resection is indicated in a greater number of cases. Although the use of endoscopic treatment for gastric cancer has been increasing steadily, long-term outcome data is necessary.

Case series of intra-abdominal adhesions induced by artificial ulceration after endoscopic submucosal dissection before additional laparoscopic gastrectomy

BACKGROUND

As endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) increases, increasing numbers of patients require additional gastrectomy with lymph node dissection after noncurative ESD. ESD may cause intra-abdominal adhesions, making additional laparoscopic gastrectomy technically difficult.

OBJECTIVE

To assess the relation of the presence of intra-abdominal adhesions and ESD treatment to allow safe laparoscopic gastrectomy.

DESIGN

Case series from a retrospective review of additional gastrectomy after noncurative ESD.

SETTING

Tertiary care center.

PATIENTS AND INTERVENTIONS

Eight of 333 patients receiving ESD at Oita University Faculty of Medicine from 1999 to 2008 underwent additional laparoscopic gastrectomy because of noncurative ESD.

MAIN OUTCOME MEASUREMENTS

Intra-abdominal adhesions were evaluated by using an adhesion scoring system (0-3 points) and clinicopathologic findings, including artificial ulcerations after ESD.

RESULTS

All patients successfully underwent laparoscopic gastrectomy within 1 to 2 months after ESD. Three patients with large artificial ulceration (>25 mm) after ESD treatment had severe intra-abdominal adhesions (adhesion score > or =2). These patients tended to have a large blood loss and long operation times during laparoscopic gastrectomy. Despite the 2-month interval from ESD to laparoscopic gastrectomy, ulcerations in these patients were at healing stage with inflammatory cells infiltrating the muscular deep layer.

LIMITATION

A retrospective study.

CONCLUSIONS

After ESD with large artificial ulceration (>25 mm), the presence of intra-abdominal adhesions complicating additional laparoscopic gastrectomy was often observed.

Predictive factors of lymph node metastasis in undifferentiated early gastric cancers and application of endoscopic mucosal resection

BACKGROUND

For intramucosal undifferentiated early gastric cancer (EGC), gastrectomy with lymphadenectomy is now the standard therapy. However, because approximately 96% of intramucosal undifferentiated EGC do not have lymph node metastasis (LNM). Gastrectomy with lymphadenectomy may be overtreatment for such patients. This study was conducted to identify clinicopathological factors predictive of LNM in undifferentiated EGC and further to expand the possibility of using endoscopic mucosal resection (EMR) for the treatment of undifferentiated EGC.

METHODS

Data from 108 patients with undifferentiated EGC and surgically treated were collected, and the association between the clinicopathological factors and the presence of LNM were retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (ORs) with 95% confidence interval (95% CI) were calculated.

RESULTS

The tumor size (OR=11.475, 95% CI: 2.054-64.104, P=0.005), depth of invasion (OR=11.704, 95% CI: 2.536-54.010, P=0.002), and lymphatic vessel involvement (LVI) (OR=13.688, 95% CI: 1.779-105.324, P=0.012) that were significantly associated with LNM by univariate analysis, were found to be significant and independent risk factors for LNM by multivariate analysis. The LNM rates were 5% (3/61) and 28% (13/47) with intramucosal and submucosal undifferentiated EGC respectively. LNM was observed in 50% (1/2) of patients with both risk factors (tumor larger than 2.0cm and the presence of LVI) but in none of 25 patients without the two risk factors in intramucosal undifferentiated EGC. The 5-year survival rates were 88%, 82% and 50%, respectively in cases with none, one and two of the risk factors respectively in intramucosal undifferentiated EGC (P<0.05).

CONCLUSIONS

A tumor larger than 2.0cm, submucosal invasion, and the presence of LVI are independently associated with the presence of LNM in undifferentiated EGC. EMR alone may be sufficient treatment for intramucosal undifferentiated EGC if the tumor is less than or equal to 2cm in size, and when LVI is absent upon postoperative histological examination. When specimens show with LVI, unexpected submucosal invasion, and unexpectedly larger tumor size than that determined at pre-EMR endoscopic diagnosis, an additional radical gastrectomy is probably better for these patients.

Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions

PURPOSE

Endoscopic submucosal dissection (ESD) technique has facilitated en bloc removal of widely spread lesions from the stomach. This retrospective study aimed to determine factors associated with serious complications of ESD.

METHODS

Between December 2001 and March 2007, we have performed ESD for 478 lesions in 436 patients. We experienced 39 patients with post-operative bleeding and 17 patients with perforation. Risk factors of patients who received ESD in gastric mucosal tumors for complications were evaluated, focusing on resected size, location, scar lesions, operation time, and experience of endoscopists. We evaluated the patients' background characteristics including sex, age, body mass index (kg/m(2)), drug history of anticoagulant, and underlying diseases including cerebrovascular disorder, ischemic heart disease, liver dysfunction, renal dysfunction, hyperuricemia, hypertension and diabetes mellitus.

RESULTS

Multivariate analysis indicated a risk factor for perforation was long operation time. Multivariate analysis indicated a significant risk factor for post-operative bleeding was size of the resected tumor.

CONCLUSIONS

This study indicated risk factors for serious complications of ESD. Large resected tumor size was a risk factor for post-operative bleeding, while long operation time was a risk factor for perforation. Information regarding operation risk factors should be useful for planning strategies for ESD.

A novel device for endoscopic submucosal dissection that combines water-jet submucosal hydrodissection and elevation with electrocautery: initial experience in a porcine model

BACKGROUND

Endoscopic submucosal dissection requires a high degree of endoscopic skill and specifically designed dissecting instruments.

OBJECTIVE

To describe the technique for endoscopic submucosal dissection when using the ERBE Hybrid Knife, which combines an ultrafine high-pressure water jet with an electrocautery needle.

DESIGN

Descriptive study (ex vivo and in vivo porcine esophagus, stomach, and colon).

INTERVENTIONS

The only instrument used for the dissection was the ERBE Hybrid Knife. The high-pressure water jet was used at a pressure between 45 and 60 bar for creating submucosal fluid elevation. After this, circumferential mucosal incisions and submucosal dissection were performed with the FORCED COAG and ENDOCUT D modes of the same device. The water jet was used intermittently during the dissection process.

MAIN OUTCOME MEASUREMENTS

At the end of the in vivo experiments, animals were killed and the organs removed for evaluation.

RESULTS

Multiple endoscopic submucosal dissection procedures were successfully performed. It was possible to create submucosal fluid cushions rapidly. Repeated fluid injections during dissection were easily facilitated with the same device. All ex vivo gastric endoscopic submucosal dissections of 50 x 40-mm lesions were completed within 10 minutes. In the in vivo studies, the mean size of the gastric and colonic specimens was 3.7 +/- 2.1 x 2.3 +/- 1 cm, and the dissections were completed within 8 minutes. No thermal injury was observed on the serosa, and no perforations were detected.

CONCLUSIONS

Endoscopic submucosal dissection can be safely and effectively achieved in a porcine model with the ERBE Hybrid Knife and should be considered a suitable device for this procedure in humans.

Long-term outcomes of endoscopic submucosal dissection in gastric neoplastic lesions at a single institution in South Korea

OBJECTIVE. Although endoscopic treatment for early gastric cancer (EGC) is an accepted therapy in South Korea and Japan, long-term outcomes remain unknown. We evaluated the clinical outcome of endoscopic submucosal dissection (ESD) for gastric dysplasia and EGC. MATERIAL AND METHODS. A total of 402 patients with gastric dysplasia and EGC were treated with ESD at a single hospital from January 2004 to December 2007. The patients underwent ESD and then received periodic endoscopic follow-up and metastatic surveys for 9-49 months (median 30 months). Resectability (en bloc or piecemeal resection), curability (complete or incomplete), local recurrence, and disease-free survival rates were estimated. RESULTS. There were 107 patients with low-grade dysplasia (LGD), 97 with high-grade dysplasia (HGD) and 198 with EGC. In EGC patients, en bloc resection was achieved in 89.7% (177/198), the complete resection rate was 87.9% (174/198), and the local recurrence rate was 5.1% (10/198). Tumor size >20 mm was significantly associated with local recurrence (odds ratio 6.45; 95% CI 1.20-20.11; p=0.001). There were significant correlations between the incidences of a piecemeal or incomplete resection and that of local recurrence (odds ratio 5.23; 95% CI 1.02-18.34; p=0.001; and odds ratio 6.99; 95% CI 1.22-21.65; p=0.002, respectively). The 3-year cancer-free survival rate was 94.9%. CONCLUSIONS. Curative treatment with successful en bloc resection can reduce the local recurrence of gastric neoplastic lesions after ESD. Clinical outcome may be excellent, although longer follow-up studies are warranted.

Endoscopic mucosal resection for staging and therapy of adenocarcinoma of the esophagus, gastric cardia, and upper gastric third

Minamally invasive endoscopic resection techniques allow definitive histological staging for dysplasia and early cancer and in many cases curative treatment. In Barrett's esophagus with High Grade Dysplasia (HGD) or early mucosal cancer, endoscopic mucosal resection (EMR) should be considered both as diagnostic and therapeutic first line procedure, with the possibility to repeat the procedure in case of residual Barrett's dysplasia or mucosal cancer. In early cancer of the the submucosa, surgical resection should be discussed. Endoscopic submucosal dissection (ESD) is a useful therapeutic option for HGD or early cancer in the squamous epithelium of the esophagus or in the stomach when en bloc resection is needed in large lesions.

Clinical advantages of endoscopic submucosal dissection for gastric cancers in remnant stomach surpass conventional endoscopic mucosal resection

AIM

Endoscopic submucosal dissection was developed to address the shortcomings of conventional endoscopic mucosal resection. The present study evaluated the benefits of endoscopic submucosal dissection compared with conventional endoscopic mucosal resection for the treatment of neoplasms arising from the remnant stomach after gastrectomy or esophagectomy.

METHODS

This study, which was designed as a historical control study, evaluated 22 gastric cancers in remnant cancers treated by conventional endoscopic mucosal resection and another 40 cancers treated by endoscopic submucosal dissection.

RESULTS

Patient characteristic between the two groups were not different except for tumor size, which was larger in patients with endoscopic submucosal dissection. The local complete resection rate and the curative resection rate were significantly higher in the endoscopic submucosal dissection group compared to those in the mucosal resection group (95.0% vs 40.9% and 80.0% vs 40.9%, respectively). Complication rate showed no significant difference in the two groups, although submucosal dissection required a longer operation time.

CONCLUSION

Endoscopic submucosal dissection represents a reliable treatment for gastric cancers in the remnant stomach, surpassing endoscopic mucosal resection.

Endoscopic submucosal dissection for metachronous tumor in the remnant stomach after distal gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) of tumor in the upper part of the stomach is technically difficult and has a high complication rate. We compared the feasibility and safety of ESD for metachronous tumor found in the remnant stomach after distal gastrectomy with ESD for tumor in the upper third of the intact stomach.

PATIENTS AND METHODS

We retrospectively compared clinical outcome and safety of 13 lesions (11 early gastric cancers (EGCs) and 2 dysplasias) in the remnant stomach and 30 lesions (28 EGCs and 2 dysplasias) in the upper third of the intact stomach. All patients were treated with ESD at a cancer center hospital.

RESULTS

En bloc resection rates were 100% (13/13) for remnant gastric tumor and 87% (26/30) for upper-third tumor (p = 0.30). En bloc resection rates with tumor-free margins (R0 resection) were 92% (12/13) for remnant gastric tumor and 73% (22/30) for upper-third tumor (p = 0.24). Curative resection rates were 85% (11/13) for remnant gastric tumor and 67% (20/30) for upper-third tumor (p = 0.29). Median procedure duration for ESD was 68 min (range 32-233 min) in the remnant stomach and 78 min (range 45-261 min) in the intact stomach (p = 0.49). One case of perforation and one of delayed bleeding occurred in the upper-third tumor group, whereas none occurred in the remnant tumor group. Local recurrence was found in no patients in the remnant gastric tumor group but in one patient in the upper-third tumor group.

CONCLUSIONS

ESD for metachronous remnant gastric tumor was feasible and safe in comparison with ESD for tumor in the upper third of the intact stomach.