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Qatomah A, Aihara H. Colorectal endoscopic submucosal dissection in the USA: The current state and future perspectives. DEN OPEN 2025; 5:e394. [PMID: 38915785 PMCID: PMC11194299 DOI: 10.1002/deo2.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/16/2024] [Accepted: 05/27/2024] [Indexed: 06/26/2024]
Abstract
Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.
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Affiliation(s)
- Abdulrahman Qatomah
- Division of Gastroenterology and HepatologyMcGill University Health CenterMontrealCanada
- Division of Gastroenterology and HepatologyKing Faisal Specialist Hospital and Research CenterJeddahSaudi Arabia
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and EndoscopyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Cocomazzi F, Carparelli S, Labarile N, Capogreco A, Gentile M, Maselli R, Dhar J, Samanta J, Repici A, Hassan C, Perri F, Facciorusso A. Is there a best choice of equipment for colorectal endoscopic submucosal dissection? Expert Rev Med Devices 2024; 21:561-577. [PMID: 38829122 DOI: 10.1080/17434440.2024.2364022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/31/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a widely used technique to remove early neoplastic lesions. It was primarily used in the initial days to treat gastric lesions, but recently, the horizon of this endoscopic procedure has expanded, which has allowed us to manage other technically more complex locations, such as the colorectum. AREAS COVERED There has been an exponential growth regarding the wide range of devices available in the market for performing colorectal ESD. As a result, the aim of this review is to highlight the indication of this endoscopic technique, which device is best suited for which indication, as well as future trajectories in this field. EXPERT OPINION Although some devices have proven to be more advantageous than others in this area, very often the choice is still subjective, which is commonly attributed to individual preferences and experience. However, an accurate knowledge of the available tools and their functioning, with their pros and cons, is fundamental for any endoscopist venturing into the field of third space endoscopy. In this way, one can choose which device best suits a particular situation, along with simultaneously having the wealth of knowledge related to therapeutic armamentarium at our disposal in the endoscopy suite.
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Affiliation(s)
- Francesco Cocomazzi
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
| | - Sonia Carparelli
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
| | - Nunzia Labarile
- Department of Gastroenterology, National Institute of Gastroenterology - IRCCS "Saverio de Bellis" - Castellana Grotte, Bari, Italy
| | - Antonio Capogreco
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
| | - Marco Gentile
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
| | - Roberta Maselli
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University - Rozzano, Foggia, Italy
| | - Jahnvi Dhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University - Rozzano, Foggia, Italy
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS - Rozzano, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University - Rozzano, Foggia, Italy
| | - Francesco Perri
- Gastroenterology and Endoscopy Unit, Fondazione "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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He XJ, Wang XL, Jiang CS, Hong DG, Lin HL, Zheng YP, Li H, Chen XJ, Huang JX, Dai LS, Liu MY, Luo BX, Li DL, Li DZ, Wang W. Novel beagle model of gastric local fibrotic target lesions for the evaluation and training of endoscopic techniques. BMC Gastroenterol 2023; 23:412. [PMID: 38012582 PMCID: PMC10683295 DOI: 10.1186/s12876-023-03055-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 11/18/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Novel endoscopic techniques used in the treatment of gastric lesions with local submucosal fibrosis need preclinical evaluation and training due to safety limitations. Therefore, the purpose of our study was to establish an animal model of gastric local fibrotic target lesions and assess its feasibility in the evaluation and training of endoscopic techniques. METHODS In six experimental beagles, a 50% glucose solution was injected into three submucosal areas of the fundus, body, and antrum of the stomach to create gastric local fibrotic target lesions (experimental group). On post-injection day (PID) 7, the injection sites were assessed endoscopically to confirm the presence of submucosal fibrosis formation, and the dental floss clip traction assisted endoscopic submucosal dissection (DFC-ESD) procedure was performed on the gastric local fibrotic target lesions to confirm its feasibility after endoscopic observation. The normal gastric mucosa of six control beagles underwent the same procedure (control group). All the resected specimens were evaluated by histological examination. RESULTS All 12 beagles survived without postoperative adverse events. On PID 7, 16 ulcer changes were observed at the injection sites (16/18) under the endoscope, and endoscopic ultrasonography confirmed the local submucosal fibrosis formation in all ulcer lesions. The subsequent DFC-ESD was successfully performed on the 32 gastric target lesions, and the mean submucosal dissection time in the ulcer lesions was greater than that in the normal gastric mucosa (15.3 ± 5.6 vs. 6.8 ± 0.8 min; P < 0.001). There was no difference in rates of en bloc resection, severe hemorrhage, or perforation between the two groups. Histological analysis of the ulcer lesions showed the absence of epithelial or muscularis mucosae and extensive submucosal fibrous tissue proliferations compared with normal gastric mucosa. Overall, endoscopists had high satisfaction with the realism and feasibility of the animal model. CONCLUSION We developed a novel animal model of gastric local fibrotic target lesions to simulate difficult clinical situations, which strongly appeared to be suitable for the preclinical evaluation and learning of advanced endoscopic techniques.
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Affiliation(s)
- Xiao-Jian He
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Xiao-Ling Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Chuan-Shen Jiang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Dong-Gui Hong
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Hai-Lan Lin
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Yun-Ping Zheng
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Han Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Xin-Jiang Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Jian-Xiao Huang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Ling-Shuang Dai
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Mei-Yan Liu
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Bao-Xiang Luo
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Dong-Liang Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Hepatobiliary Disease, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
| | - Da-Zhou Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
| | - Wen Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
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Pan M, Zhang MM, Zhao L, Lyu Y, Yan XP. Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer. World J Gastrointest Endosc 2023; 15:658-665. [DOI: 10.4253/wjge.v15.i11.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Gastric cancer (GC) has high morbidity and mortality. Moreover, because GC has no typical symptoms in the early stages, most cases are already in the advanced stages by the time the symptoms appear, thus resulting in poor prognosis and a low survival rate. Endoscopic submucosal dissection (ESD) can realize the early detection and diagnosis of GC and become the main surgical method for early GC. However, ESD has a steep learning curve and high technical skill requirements for endoscopists, which is not conducive to its widespread implementation and advancement. Therefore, a series of auxiliary techniques have been derived.
AIM To evaluate the safety and efficacy of magnetic anchor technique (MAT)-assisted ESD in early GC.
METHODS This was an ex vivo animal experiment. The experimental models were the isolated stomachs of pigs, which were divided into two groups, namely the study group (n = 6) with MAT-assisted ESD and the control group (n = 6) with traditional ESD. Comparing the total surgical time, incidence of surgical complications, complete mucosal resection rate, specimen size, and the scores of endoscopist’s satisfaction with the procedure reflected their feelings about convenience during the surgical procedure between the two groups. The magnetic anchor device for auxiliary ESD in the study group comprised three parts, an anchor magnet (AM), a target magnet (TM), and a soft tissue clip. Under gastroscopic guidance, the soft tissue clip and the TM were delivered to the pre-marked mucosal lesion through the gastroscopic operating hole. The soft tissue clip and the TM were connected by a thin wire through the TM tail structure. The soft tissue clip was released by manipulating the operating handle of the soft tissue clip in a way that the soft tissue clip and the TM were fixed to the lesion mucosa. In vitro, ESD is aided by maneuvering the AM such that the mucosal dissection surface is exposed.
RESULTS The total surgical time was shorter in the study group than in the control group (26.57 ± 0.19 vs 29.97 ± 0.28, P < 0.001), and the scores of endoscopist’s satisfaction with the procedure were higher in the study group than in the control group (9.53 ± 0.10 vs 8.00 ± 0.22, P < 0.001). During the operation in the study group, there was no detachment of the soft tissue clip and TM and no mucosal tearing. The magnetic force between the AM and TM provided good mucosal exposure and sufficient tissue tension for ESD. The mucosal lesion was completely peeled off, and the operation was successful. There were no significant differences in the incidence of surgical complications (100% vs 83.3%), complete mucosal resection rate (100% vs 66.7%, P = 0.439), and specimen size (2.44 ± 0.04 cm vs 2.49 ± 0.02, P = 0.328) between the two groups.
CONCLUSION MAT-ESD is safe and effective for early GC. It provides a preliminary basis for subsequent internal animal experiments and clinical research.
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Affiliation(s)
- Min Pan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
| | - Miao-Miao Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
| | - Lin Zhao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
- Zonglian College, Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
| | - Yi Lyu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
| | - Xiao-Peng Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an 710061, Shaanxi Province, China
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Wang XL, He XJ, Jiang CS, Hong DG, Zheng YP, Li H, Chen XJ, Huang JX, Dai LS, Liu MY, Li DZ, Wang W. Magnetic ring-assisted endoscopic submucosal dissection for gastric lesions with submucosal fibrosis: A preliminary study in beagle model. Asian J Surg 2023; 46:3673-3679. [PMID: 37120374 DOI: 10.1016/j.asjsur.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND During endoscopic submucosal dissection (ESD) for gastric lesions with fibrosis, appropriate traction could provide clear submucosal dissection visualization to improve safety and efficiency of procedures. Therefore, the aim of this study was to evaluate the feasibility of magnetic ring-assisted ESD (MRA-ESD) for gastric fibrotic lesions. METHOD In the eight healthy beagles, 2-3 mL of 50% glucose solution was injected into submucosal layer of the stomach to induce gastric fibrotic lesions. A week after submucosal injection, two endoscopists at different levels performed MRA-ESD or standard ESD (S-ESD) for gastric simulated lesions, respectively. The magnetic traction system consisted of external handheld magnet and internal magnetic ring. The feasibility and procedure outcomes of the magnetic traction system were mainly evaluated. RESULTS Forty-eight gastric simulated lesions with ulceration were confirmed to have submucosal fibrosis formation by preoperative endoscopic ultrasonography. The magnetic traction system could be easily established, only took 1.57 min, and allowed excellent submucosal visualization. The total procedure time was significantly shorter in the MRA-ESD group than in the S-ESD group for both endoscopists (mean: 46.83 vs. 25.09 min, p < 0.001), and this difference was accentuated in non-skilled endoscopist. There was significant difference between two groups in bleeding and perforation rates. Histological analysis showed the depth of resected specimens was a little deeper around the fibrotic portion in the S-ESD group (p < 0.001). CONCLUSION The magnetic ring-assisted ESD technique may be an effective and safe treatment for gastric fibrotic lesions and may shorten the endoscopic learning curve for non-skilled endoscopists.
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Affiliation(s)
- Xiao-Ling Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Xiao-Jian He
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Chuan-Shen Jiang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Dong-Gui Hong
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Yun-Ping Zheng
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Han Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Xin-Jiang Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Jian-Xiao Huang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Ling-Shuang Dai
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Mei-Yan Liu
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Da-Zhou Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
| | - Wen Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
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Nagata M, Namiki M, Fujikawa T, Munakata H. Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos). Dig Dis Sci 2023; 68:2531-2544. [DOI: https:/doi.org/10.1007/s10620-023-07870-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/03/2023] [Indexed: 05/21/2023]
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Miyazaki K, Kato M, Sasaki M, Iwata K, Masunaga T, Kubosawa Y, Hayashi Y, Mizutani M, Takatori Y, Matsuura N, Nakayama A, Takabayashi K, Nakajima K, Kanai T, Yahagi N. First clinical experience with esophageal ESD using a novel adjustable traction device. Endosc Int Open 2023; 11:E446-E450. [PMID: 37180311 PMCID: PMC10169228 DOI: 10.1055/a-2011-1836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023] Open
Abstract
Background and study aims In esophageal endoscopic submucosal dissection (ESD), the effectiveness of traction including clip-thread method has been reported, but it is difficult to adjust the direction of traction. Therefore, we developed a dedicated over-tube type traction device (ENDOTORNADO) that has a working channel and allows traction from any directions by rotating itself. We investigated the clinical feasibility and potential usefulness of this new device in esophageal ESD. Patients and methods This was a single-center, retrospective study. Six cases of esophageal ESD with ENDOTORNADO from January to March 2022 (tESD group) were compared with 23 cases of conventional esophageal ESD performed by the same operator from January 2019 to December 2021 (cESD group) in terms of clinical treatment outcomes. Results In all cases, en bloc resection was achieved without intraoperative perforation. The total procedure speed was significantly increased in tESD group (23 vs. 30 mm 2 /min, P = 0.046). In particular, the submucosal dissection time was significantly reduced to about one-quarter in tESD group (11 vs. 42 min, P = 0.004). Conclusions ENDOTORNADO creates the adjustable traction from any directions and may have the clinical feasibility. It would be an option for human esophageal ESD.
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Affiliation(s)
- Kurato Miyazaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Iwata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Teppei Masunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Kubosawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yukie Hayashi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyokazu Nakajima
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Visrodia K, Dobashi A, Bazerbachi F, Poneros J, Sethi A. Endoscopic Submucosal Dissection Facilitating Techniques Among Non-experts: A Systematic Literature Review. Dig Dis Sci 2023; 68:2561-2584. [PMID: 37024739 DOI: 10.1007/s10620-022-07784-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/30/2022] [Indexed: 04/08/2023]
Abstract
BACKGROUND AND AIMS The dissemination of endoscopic submucosal dissection (ESD) has been limited by its technical complexity and safety profile, particularly among non-experts. Various techniques and devices have facilitated the performance of ESD, but their yield and role in the path to learning ESD remain unclear. METHODS We performed a systematic review by querying MEDLINE, EMBASE, Web of Science, and Japan Medical Abstracts Society specifically for comparative studies investigating the impact of assigned ESD techniques vs. conventional techniques among non-experts in ESD (< 50 ESD procedures). Procedural outcomes of efficacy, efficiency, and safety were assessed. RESULTS We identified 46 studies evaluating 54 cohorts in which a total 237 non-experts performed 2461 ESDs conventionally, and 1953 ESDs using an assigned ESD technique (knives, countertraction, miscellaneous techniques). The majority of studies were from East Asia (67%), single-center (96%), observational in design (61%), in an animal model (57%), and gastric location (63%). The most studied techniques were countertraction techniques (48% cohorts) and scissor knives (15% cohorts), both of which commonly enhanced efficiency of ESD, and less so efficacy or safety. Techniques found to be beneficial in experts were more likely to be beneficial in non-experts (70% concordance) than vice versa (47% concordance). CONCLUSION Based on the currently available literature, countertraction techniques and scissor knives should be considered for early incorporation into ESD training by non-experts. Several aspects of ESD training remain understudied, including techniques in Western non-experts, educational resources, and several commonly cited techniques. These areas should guide future investigation to enhance the pathway to learning ESD.
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Affiliation(s)
- Kavel Visrodia
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, 161 Fort Washington Ave, 8th Fl, Ste 852A, New York, NY, 10032, USA.
| | - Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, MN, USA
| | - John Poneros
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, 161 Fort Washington Ave, 8th Fl, Ste 852A, New York, NY, 10032, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, 161 Fort Washington Ave, 8th Fl, Ste 852A, New York, NY, 10032, USA
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Furube T, Takeuchi M, Kawakubo H, Maeda Y, Matsuda S, Fukuda K, Nakamura R, Kitagawa Y. The relationship between the esophageal endoscopic submucosal dissection technical difficulty and its intraoperative process. Esophagus 2023; 20:264-271. [PMID: 36508068 DOI: 10.1007/s10388-022-00974-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Estimating the esophageal endoscopic submucosal dissection (ESD) technical difficulty is important to reduce complications. Endoscopic duration is one of the related factors to a technical difficulty. The relationship between the esophageal ESD technical difficulty and its intraoperative process was analyzed as a first step toward automatic technical difficulty recognition using artificial intelligence. METHODS This study enrolled 75 patients with superficial esophageal cancer who underwent esophageal ESD. The technical difficulty score was established, which consisted of three factors, including total procedure duration, en bloc resection, and complications. Additionally, technical difficulty-related factors, which were perioperative factors that included the intraoperative process, were investigated. RESULTS Eight (11%) patients were allocated to high difficulty, whereas 67 patients (89%) were allocated to low difficulty. The intraoperative process, which was shown as the extension of each endoscopic phase, was significantly related to a technical difficulty. The area under the curve (AUC) values were higher at all the phase duration than at the clinical characteristics. Submucosal dissection phase (AUC 0.902; 95% confidence intervals (CI) 0.752-1.000), marking phase (AUC 0.827; 95% CI 0.703-0.951), and early phase which was defined as the duration from the start of marking to the end of submucosal injection (AUC 0.847; 95% CI 0.701-0.992) were significantly related to technical difficulty. CONCLUSIONS The intraoperative process, particularly early phase, was strongly associated with esophageal ESD technical difficulty. This study demonstrated the potential for automatic evaluation of esophageal ESD technical difficulty when combined with an AI-based automatic phase evaluation system.
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Affiliation(s)
- Tasuku Furube
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Yusuke Maeda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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10
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Yang X, Fu S, Li L, Yang J, Ji R, Li Y, Zuo X. Robot-assisted endoscopic submucosal dissection contributes to efficient and safe learning for novices: Prospective pilot cross-over ex vivo study (with video). Dig Endosc 2023; 35:342-351. [PMID: 36107632 DOI: 10.1111/den.14438] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/12/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The lack of effective countertraction to expose the submucosal layer contributes to the technical complication and adverse events in endoscopic submucosal dissection (ESD). We aimed to evaluate the efficacy and safety of a novel endoscopic robot (flexible auxiliary single-arm transluminal endoscopic robot [FASTER]) for ESD learning for novices. METHODS This was a prospective, cross-over designed pilot study in ex vivo porcine stomach. Four ESD novices were randomized to either FASTER-assisted ESD first (FC) group or a conventional ESD first (CF) group, performed 40 gastric ESDs using each technique, then crossed over to another technique. The performance and learning curve were compared between the two groups. RESULTS In the first phase, novices in the FC group demonstrated significantly better performance with shorter procedure time (25.6 ± 7.8 vs. 38.9 ± 13.4 min; P < 0.001) and submucosal dissection time (13.9 ± 5.5 vs. 23.1 ± 11.0 min; P < 0.001), higher direct-vision dissection ratio (84.0 ± 7.9% vs. 43.5 ± 20.7%; P < 0.001), and lower muscular injury (2.5 vs. 40.0%; P < 0.001) and task load (4 vs. 5; P < 0.001). Fewer ESDs were required to gain early proficiency in the FC group. When crossed to the second phase, procedure time in the FC group was prolonged but the muscular injury rate did not increase significantly. In total, endoscopists in the FC group tended to have a lower task load (4 vs. 5; P = 0.008) and less muscular injury (10.0 vs. 21.3%; P = 0.05). CONCLUSION Flexible auxiliary single-arm transluminal endoscopic robot-assisted learning reduces the technical difficulty of ESD for novices and the safety profile can sustain in following conventional ESD. These results indicated that FASTER has potential implications for ESD training in clinical practice.
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Affiliation(s)
- Xiaoxiao Yang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Shichen Fu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Lixiang Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Jialin Yang
- Robo Medical Robotics Institute, Shenzhen Robo Medical Technology Co., Ltd, Shenzhen, China
| | - Rui Ji
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Yanqing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiuli Zuo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
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11
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Takada K, Yoshida M. Simple add-on robotic traction device to the conventional endoscope: Will it be an efficient and safe tool for novice training on endoscopic submucosal dissection? Dig Endosc 2023; 35:352-353. [PMID: 36442840 DOI: 10.1111/den.14471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kazunori Takada
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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12
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Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos). Dig Dis Sci 2023; 68:2531-2544. [PMID: 36853551 PMCID: PMC9971682 DOI: 10.1007/s10620-023-07870-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/03/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The impact of traction direction in traction-assisted gastric endoscopic submucosal dissection (ESD) has not been adequately investigated. A clip with line (CWL) is a classical single-directional traction device. In contrast, a spring and loop with clip (SLC; S-O clip) is a newly developed multidirectional traction device. AIMS To investigate the impact of traction direction in gastric ESD by comparing the procedure-related outcomes of CWL-assisted ESD (CWL-ESD) and SLC-assisted ESD (SLC-ESD). METHODS We retrospectively examined 140 patients with superficial gastric neoplasms who underwent SLC-ESD or CWL-ESD by a single ESD expert during November 2017-September 2020. The traction direction was classified based on the endoscopic finding in the following five categories: proximal, diagonally proximal, vertical, diagonally distal, and distal. In SLC-ESD, we set vertical traction, using the multidirectional traction function. Propensity score matching was conducted to compensate for the differences in lesion size, injection function of electrosurgical knife, ulcerative lesion, lesion location, and lesion position. The primary outcome was gastric ESD procedure time. RESULTS Propensity score matching created 42 pairs. The median gastric ESD procedure time in the SLC-ESD group was significantly shorter than that in the CWL-ESD group (28.3 min vs. 51.0 min, P = 0.022). All traction direction in the SLC-ESD group was vertical, while only 16.7% in the CWL-ESD group. En bloc resection was attained without perforation in all the patients in both groups. CONCLUSION Our findings suggest that SLC can provide vertical traction, which reduces the gastric ESD procedure time. Multidirectional traction devices can provide vertical traction in most cases of gastric ESD, unlike single-directional traction devices. Vertical traction may reduce the gastric ESD procedure time.
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13
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Yang D, Hasan MK, Draganov PV. East versus West: Comparisons and Implications in Adaptation to Practice. Gastrointest Endosc Clin N Am 2023; 33:7-13. [PMID: 36375888 DOI: 10.1016/j.giec.2022.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endoscopic submucosal dissection (ESD) is the preferred strategy for the resection of large superficial neoplasia throughout the gastrointestinal tract in Asian countries. The transition of ESD to the West has been slower because of various regional and training differences. Nonetheless, over the past couple of decades, the steady growth of ESD mentors in the West and the introduction of viable training pathways and dedicated devices and accessories have led to the increasing adoption of ESD and other third space endoscopic procedures.
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Affiliation(s)
- Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16(th) Street, Room #5262, Gainesville, FL 32608, USA.
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14
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Simsek C, Aihara H. Training in Endoscopic Submucosal Dissection in the United States: The Current Paradigm. Gastrointest Endosc Clin N Am 2023; 33:41-53. [PMID: 36375885 DOI: 10.1016/j.giec.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endoscopic submucosal dissection (ESD) training in Japan is pursued through a designated master-apprentice, organ-based stepwise training model. However, applying a similar program to the United States is not a practical strategy due to the significant differences in the training system and disease prevalence. To incorporate the ESD training into the current advanced endoscopy fellowship program, the use of recently developed techniques and technologies to improve the efficiency of ESD is ideal. The ESD training program in the United States should be prevalence-based, with increased involvement of trainees depending on their objectively assessed competency levels.
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Affiliation(s)
- Cem Simsek
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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15
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A Look into the Future of Endoscopic Submucosal Dissection and Third Space Endoscopy: The Role for Robotics and Other Innovation. Gastrointest Endosc Clin N Am 2023; 33:197-212. [PMID: 36375883 DOI: 10.1016/j.giec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endoscopic resection has been widely applied especially in endoscopic submucosal dissection and third space endoscopy (TSE). Flexible endoluminal robotics allow performance of endoscopic submucosal dissection with exposure of the submucosal plane for precise dissection using two robotic arms. The introduction of TSE revolutionized the horizon of therapeutic endoscopy to the submucosal space beneath and beyond the mucosa. Advantages of TSE include avoidance of full thickness incision in gastrointestinal tract through the submucosal tunneling for performance of peroral endoscopic myotomy and submucosal tunneling endoscopic resection. In future, robotic-driven devices should be developed to enhance performance of complex endoluminal procedures and TSE.
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16
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Nagata M. Optimal traction direction in traction-assisted gastric endoscopic submucosal dissection. World J Gastrointest Endosc 2022; 14:667-671. [PMID: 36438880 PMCID: PMC9693688 DOI: 10.4253/wjge.v14.i11.667] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/02/2022] [Accepted: 10/14/2022] [Indexed: 11/14/2022] Open
Abstract
Various traction devices have been developed to secure a visual field and sufficient tension at the dissection plane during endoscopic submucosal dissection (ESD). However, few large-scale studies have investigated the effectiveness of traction devices in gastric ESD. Clip-with-line (CWL) is one such traction device that is widely used in cases of gastric ESD. The CONNECT-G trial was the first multicenter randomized controlled trial to compare conventional ESD with CWL-assisted ESD (CWL-ESD) for superficial gastric neoplasms. Overall, no significant intergroup difference was observed in terms of the gastric ESD procedure time. However, subgroup analysis according to lesion location revealed a significant reduction in the procedure time of gastric ESD for the lesion located at the greater curvature of the middle and upper third of the stomach in the CWL-ESD group. In this subgroup analysis, lesion location was categorized as follows: anterior wall, posterior wall, lesser curvature, and greater curvature of the upper, middle, and lower thirds of the stomach. However, the gastric ESD procedure time showed no significant difference, except for lesions located at the greater curvature of the upper and middle thirds of the stomach. The traction direction of CWL in the stomach was limited to the cardia and changed depending on the lesion location. Therefore, outcomes of the CONNECT-G trail suggest that the effectiveness of CWL was influenced by lesion location, i.e., traction direction. Further studies are warranted to investigate the optimal traction direction in gastric ESD.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa 251-0041, Kanagawa, Japan
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17
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Tabata M, Nakamura R, Tatsuki S. Technical tips in non-robotic endoscopic mitral valve surgery: How to approach and expose the mitral valve. Asian Cardiovasc Thorac Ann 2022; 30:645-652. [PMID: 35509175 DOI: 10.1177/02184923221086060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The non-robotic endoscopic mitral valve surgery is performed via a right mini-thoracotomy without the use of rib spreader or robotic assistance. Although it has several advantages over the direct vision minimally invasive and robotic approaches, operating in very limited working space without robotic assistance is technically demanding. In the first place, it is impossible to perform non-robotic endoscopic mitral valve surgery safely and efficiently without knowing how to approach and expose the mitral valve in very limited working space without robotic assistance. This manuscript introduces detailed technical tips for efficient approach and uncompromised exposure of the mitral valve in non-robotic endoscopic mitral valve surgery, including separate bicaval cannulation, decentralized positioning of the instruments, controlling the direction of traction sutures and appropriate use of retractors.
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Affiliation(s)
- Minoru Tabata
- Department of Cardiovascular Surgery, 38507Tokyo Bay Urayasu Ichikawa Medical Center, Japan.,Department of Cardiovascular Surgery, 13600Toranomon Hospital, Japan.,Department of Cardiovascular Surgery, 12847Juntendo University Graduate School of Medicine, Japan
| | - Ryota Nakamura
- Department of Cardiovascular Surgery, 38507Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Suguru Tatsuki
- Department of Cardiovascular Surgery, 13600Toranomon Hospital, Japan
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18
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Abstract
Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Kanagawa 251-0041, Japan.
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19
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Nagata M. Advances in traction methods for endoscopic submucosal dissection: What is the best traction method and traction direction? World J Gastroenterol 2022; 28:1-22. [PMID: 35125817 PMCID: PMC8793018 DOI: 10.3748/wjg.v28.i1.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/13/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Kanagawa 251-0041, Japan
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20
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Visrodia K, Sawas T, Zakko L, Genere JR, Leggett C, Lutzke L, Wang KK. Scissor-type knife improves the safety of endoscopic submucosal dissection (ESD) among endoscopists without experience in ESD: a randomized ex vivo study. Endosc Int Open 2021; 9:E1207-E1213. [PMID: 34447866 PMCID: PMC8383092 DOI: 10.1055/a-1487-5469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/19/2020] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Endoscopic submucosal dissection (ESD) is technically challenging, difficult to learn, and carries a substantial risk of perforation, all of which remain significant barriers to its adoptability. We aimed to determine whether use of a novel scissor-type knife improved efficacy and safety among novice performers of ESD. Materials and methods Following a brief didactic session on ESD, participants performed ESD of two lesions (2 cm diameter) in an ex vivo porcine gastric model. One resection was performed with a conventional knife and the other with the scissor knife (order of knife randomized). We recorded procedure time, successful en bloc resection, and adverse events (including full-thickness perforation and muscle injury) for each dissection. Participants completed a post-study survey. Results 10 endoscopists (8 trainees, 2 staff) considered novices in ESD participated. Compared with the conventional knife, use of the scissor knife was associated with a significantly shorter time to completion of submucosal dissection (mean 6.2 [SD 5.6] vs. 15.6 [SD 15.6] minutes; P = 0.04) and total procedure time was not significantly different (22.1 [SD 13.3] vs. 24.9 [SD 26.5] minutes; P = 0.65). Scissor knife use was also associated with a significantly lower proportion of perforation and/or muscle injury (10.0 % vs. 70.0 %; P < 0.01) and proportion of muscle injury alone (10.0 % vs. 60.0 %; P = 0.02). Conclusions Among novices performing ESD on an ex vivo animal model, use of a scissor knife was associated with a significantly lower proportion of adverse events without prolonging procedure time. Scissor-type knives may improve ESD safety, at least among novices.
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Affiliation(s)
- Kavel Visrodia
- Digestive and Liver Diseases, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, United States
| | - Tarek Sawas
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas, United States
| | - Liam Zakko
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Juan Reyes Genere
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Cadman Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Lori Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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21
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Nagata M, Fujikawa T, Munakata H. Comparing a conventional and a spring-and-loop with clip traction method of endoscopic submucosal dissection for superficial gastric neoplasms: a randomized controlled trial (with videos). Gastrointest Endosc 2021; 93:1097-1109. [PMID: 33058886 DOI: 10.1016/j.gie.2020.09.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Several traction methods have sought to overcome the technical difficulties of endoscopic submucosal dissection (ESD). However, traction direction has remained limited in most of these methods, with lack of clarity about the optimal method and traction direction for gastric ESD. A spring-and-loop with clip (SLC) has been developed as a multidirectional traction device. Here, we investigated whether SLC traction-assisted ESD (SLC-ESD) improved procedure-related outcomes compared with conventional ESD (C-ESD) among patients with superficial gastric neoplasms. METHODS This single-center randomized controlled trial included patients with superficial gastric neoplasms undergoing SLC-ESD or C-ESD between October 2018 and December 2019. Using the multidirectional traction function, we set traction vertical to the gastric wall for SLC-ESD. The primary outcome was the median procedure time for gastric ESD. RESULTS The SLC-ESD and C-ESD groups comprised 40 patients each, and all the enrolled patients underwent the assigned treatment. The median ESD procedure time was significantly shorter in the SLC-ESD group (29.1 minutes) than in the C-ESD group (52.6 minutes; P = .005). SLC had a mean attachment time of 1.82 minutes. En bloc resection was achieved without perforation in all the patients in both groups. CONCLUSIONS Our findings suggest that SLC-ESD reduces gastric ESD procedure time without increasing the risk of perforation and that the vertical direction to the gastric wall is the appropriate traction direction for gastric ESD. (Clinical trial registration number: UMIN 000034533.).
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa-shi, Kanagawa, Japan
| | - Tomoaki Fujikawa
- Center for Digestive and Hepato-Biliary-Pancreatic disease, Shonan Fujisawa Tokushukai Hospital, Fujisawa-shi, Kanagawa, Japan
| | - Hiromi Munakata
- Center for Digestive and Hepato-Biliary-Pancreatic disease, Shonan Fujisawa Tokushukai Hospital, Fujisawa-shi, Kanagawa, Japan
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22
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McCarty TR, Aihara H. Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA. Dig Endosc 2020; 32:851-860. [PMID: 31797470 DOI: 10.1111/den.13591] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
Abstract
Endoscopic submucosal dissection (ESD) is a rigorous and technically sophisticated method for removal of lesions within the gastrointestinal tract. Despite having advantages of en-bloc resection of lesions, regardless of size, and widespread use in Japan and Asia, ESD has not become widely adopted in the USA for a variety of reasons. Based upon Japanese education and the master-apprentice model, modification to the education system and additional techniques designed to facilitate broader adoption are required for trainees in the USA. This article will review the current state of education and training for ESD in the USA.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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23
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Ge PS, Aihara H. A novel clip-band traction device to facilitate colorectal endoscopic submucosal dissection and defect closure. VideoGIE 2020; 5:180-186. [PMID: 32426563 PMCID: PMC7221251 DOI: 10.1016/j.vgie.2020.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Phillip S Ge
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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24
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Ge PS, Angsuwatcharakon P, Chang GJ, Foo WC, Tillman MM, Aihara H. The suture pulley countertraction method for challenging rectal endoscopic submucosal dissection. VideoGIE 2020; 5:210-212. [PMID: 32426573 PMCID: PMC7221288 DOI: 10.1016/j.vgie.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Phillip S Ge
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Phonthep Angsuwatcharakon
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George J Chang
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wai Chin Foo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Tillman
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Hwang M, Lee SW, Park KC, Sul HJ, Kwon DS. Evaluation of a robotic arm-assisted endoscope to facilitate endoscopic submucosal dissection (with video). Gastrointest Endosc 2020; 91:699-706. [PMID: 31751551 DOI: 10.1016/j.gie.2019.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is considered technically difficult and challenging using a conventional flexible endoscope, mainly due to the lack of proper countertraction to expose the submucosal dissection plane. This study aimed to evaluate the feasibility of a traction method using a dexterous robotic arm in ex vivo gastric ESD. METHODS ESD was performed in a total of 45 procedures using a portable endoscopic tool handler (PETH) (n = 30) and using the conventional method (n = 15) at various locations in the stomach. For each procedure, the performance data were recorded, including the total procedure time (minutes), incision time (minutes), dissection speed (mm2/minute), and blind dissection rate (%), to enable a comparison of the 2 ESD methods. RESULTS The total procedure time was significantly shorter with PETH-ESD than in conventional ESD (23 vs 36 minutes, P = .011). This result is mainly attributed to the dissection speed, which was significantly faster, by more than 2.5 times, using the PETH (122.3 ± 76.5 vs 47.5 ± 26.9 mm2/minute, P < .001). The blind dissection rate was greatly decreased in PETH-ESD (0 vs 20%, P < .001). There was no significant difference in the incision time (6.1 ± 5.0 vs 5.5 ± 2.9 min, P = .612). CONCLUSIONS The countertraction method using the PETH significantly improved the dissection speed and reduced blind dissection by enhancing direct visualization of the submucosal plane. With the advantages of multidirectional traction, fine tension control, and regrasping, this new device is expected to improve the performance of ESD and further facilitate advanced endoscopic procedures.
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Affiliation(s)
- Minho Hwang
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Seung Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Cheol Park
- Clinical Research Institute, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Hae Joung Sul
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Soo Kwon
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
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Stasinos I, Toyonaga T, Suzuki N. Double-tunneling butterfly method for endoscopic submucosal dissection of extensive rectal neoplasms. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2020; 5:80-85. [PMID: 32051917 PMCID: PMC7004922 DOI: 10.1016/j.vgie.2019.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is the preferred technique for en bloc resection of superficial colorectal neoplasms. Resection of extensive lesions with ESD can be challenging, owing to loss of orientation in the submucosal space. In this case series, we describe the double-tunneling (DoT) butterfly method for ESD of extensive rectal neoplasms. METHODS The key feature of the DoT butterfly method is the creation of 2 tunnels that are transformed into bilateral flaps, leaving a submucosal septum between them. RESULTS Four rectal neoplasms measuring (maximum diameter) 7 cm, 8 cm, 9 cm, and 18 cm, respectively, were resected in 4 patients by use of the DoT butterfly method. The lesions included recurrent adenoma (n = 1) and dysplasia (n = 1) in longstanding ulcerative colitis. Curative R0 resection was confirmed in all 4 cases. Histologic examination showed tubular adenomas with low-grade dysplasia in 1 of 4 patients and focal high-grade dysplasia in 3 of 4 patients. One patient experienced postprocedural bleeding that required endoscopic reintervention. CONCLUSION The DoT butterfly method appears to be useful for the resection of extensive rectal neoplasms. A prospective study is required to assess whether these results can be reproduced in a large cohort of patients.
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Affiliation(s)
- Ioannis Stasinos
- The Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | | | - Noriko Suzuki
- The Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
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27
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Uppal DS, Wang AY. Traction-assisted endoscopic submucosal dissection in the esophagus: Should we all be flossing? Gastrointest Endosc 2020; 91:66-69. [PMID: 31865997 DOI: 10.1016/j.gie.2019.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 09/27/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Dushant S Uppal
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
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28
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Yoshida M, Takizawa K, Nonaka S, Shichijo S, Suzuki S, Sato C, Komori H, Minagawa T, Oda I, Uedo N, Hirasawa K, Matsumoto K, Sumiyoshi T, Mori K, Gotoda T, Ono H, Takizawa K, Ono H, Mori K, Nonaka S, Oda I, Shichijo S, Uedo N, Suzuki S, Kusano C, Gotoda T, Sato C, Hirasawa K, Komori H, Takeda T, Matsumoto K, Minagawa T, Fujii R, Sumiyoshi T, Yamasaki Y, Minashi K, Nakajima T, Kurokawa Y. Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2020; 91:55-65.e2. [PMID: 31445039 DOI: 10.1016/j.gie.2019.08.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is widely used as a minimally invasive treatment for large esophageal cancers, but prolonged procedure duration and life-threatening adverse events remain matters of concern. We aimed to determine whether traction-assisted ESD (TA-ESD) is superior to conventional ESD in terms of technical outcomes. METHODS A superiority, randomized, phase III trial was conducted at 7 institutions across Japan. Patients with large esophageal cancer (defined as tumor diameter >20 mm) were eligible for this study. Enrolled patients were randomly assigned to undergo conventional ESD or TA-ESD. The primary endpoint was ESD procedure duration. RESULTS Two hundred forty-one patients were recruited and randomized. On applying exclusion criteria, 117 and 116 patients who underwent conventional ESD and TA-ESD, respectively, were included in the baseline analysis. In 1 patient, conventional ESD was discontinued because of severe perforation. Thus, the final analysis included 116 patients per group (primary analysis). The ESD procedure duration was significantly shorter for TA-ESD than for conventional ESD (44.5 minutes vs 60.5 minutes, respectively; P < .001). Moreover, no adverse events were noted in the TA-ESD group. The rate of horizontal margin involvement did not differ between the groups (10.3% vs 6.9% for conventional ESD and TA-ESD, respectively; P = .484). CONCLUSIONS TA-ESD was superior to conventional ESD in terms of procedure duration and was not associated with any adverse events. TA-ESD should be considered the procedure of choice for large esophageal cancers. (Clinical trial registration number: UMIN000024080.).
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Affiliation(s)
- Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Satoru Nonaka
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Chiko Sato
- Division of Endoscopy, Yokohama City University Medical Center, Kanagawa, Japan
| | - Hiroyuki Komori
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | | | - Ichiro Oda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center, Kanagawa, Japan
| | - Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | | | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Turiani Hourneaux de Moura D, Aihara H, Jirapinyo P, Farias G, Hathorn KE, Bazarbashi A, Sachdev A, Thompson CC. Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video). Gastrointest Endosc 2019; 90:290-298. [PMID: 30922861 DOI: 10.1016/j.gie.2019.03.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/06/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities. METHODS This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload. RESULTS Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P < .0001). The perforation rate was higher in the ESD group (60% vs 30%, P = .18). Total procedure time (34.1 vs 88.6 min, P = .001) and dissection time (27.8 vs 79.4 minutes, P = .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P = .01). CONCLUSIONS RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Endoscopy Unit, Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Galileu Farias
- Endoscopy Unit, Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amit Sachdev
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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30
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Development and clinical outcomes of an endoscopic submucosal dissection fellowship program: early united states experience. Surg Endosc 2019; 34:829-838. [DOI: 10.1007/s00464-019-06836-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/15/2019] [Indexed: 02/06/2023]
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31
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Yang D, Draganov PV. Gaining traction: pulley-ing your weight during endoscopic submucosal dissection. Gastrointest Endosc 2019; 89:185-187. [PMID: 30567675 DOI: 10.1016/j.gie.2018.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/20/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
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