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Li J, Lu G, Yin Y, Lu X, Ma F, Lv Y, He S, Ren M. Efficacy, safety, and advantages of magnetic anchor-guided endoscopic submucosal dissection vs conventional endoscopic submucosal dissection: A retrospective paired cohort study. J Gastrointest Surg 2024; 28:394-401. [PMID: 38583889 DOI: 10.1016/j.gassur.2024.01.009] [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: 10/13/2023] [Revised: 01/05/2024] [Accepted: 01/13/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) has been recommended as the first-line treatment for early gastric cancer (EGC). However, poor visualization of the operative field increases both the procedure time and the risk of complications, especially for large and difficult lesions. We introduced a novel technique, magnetic anchor-guided ESD (MAG-ESD) and compared it with conventional ESD (C-ESD) for the treatment of large EGCs in terms of efficacy, safety, and advantages. METHODS Patients with large EGCs who underwent MAG-ESD or C-ESD at the First Affiliated Hospital of Xi'an Jiaotong University from March 2020 to March 2022 were retrospectively enrolled in this study. The patients in the MAG-ESD cohort were matched to those in the C-ESD cohort using propensity score-based matching. The operation time, submucosal dissection time, complete resection status, magnetic anchor, adverse event rate, and tumor recurrence rate were evaluated. RESULTS Twenty-two patients who underwent MAG-ESD were ultimately matched to those who underwent C-ESD. The median operation time of MAG-ESD and C-ESD was 43 minutes (IQR, 35.2-49.5) and 50.5 minutes (IQR, 42.0-76.0), respectively, among which the submucosal dissection time was 7.6 minutes (IQR, 5.2-10.4) and 14.8 minutes (IQR, 10.8-19.6), respectively. The operation time of MAG-ESD was shorter than that of C-ESD, especially the submucosal dissection time (P < .05). There was a lower incidence of adverse events associated with MAG-ESD (P < .05) when magnetic anchors were successfully placed and retrieved. CONCLUSION MAG-ESD is feasible, effective, safe, and simple for the treatment of large EGCs at different sites and has a high anchor success rate, which could shorten the operation time and reduce the adverse event rate.
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Affiliation(s)
- Jing Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Shaanxi Clinical Research Center of Digestive Disease (Cancer Division), Xi'an, Shaanxi, China
| | - Guifang Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Shaanxi Clinical Research Center of Digestive Disease (Cancer Division), Xi'an, Shaanxi, China
| | - Yan Yin
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Shaanxi Clinical Research Center of Digestive Disease (Cancer Division), Xi'an, Shaanxi, China
| | - Xinlan Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Shaanxi Clinical Research Center of Digestive Disease (Cancer Division), Xi'an, Shaanxi, China
| | - Feng Ma
- National and Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yi Lv
- National and Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shuixiang He
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Shaanxi Clinical Research Center of Digestive Disease (Cancer Division), Xi'an, Shaanxi, China; National and Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Mudan Ren
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Shaanxi Clinical Research Center of Digestive Disease (Cancer Division), Xi'an, Shaanxi, China; National and Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Application of in vivo traction-assisted resection of proximal colon lesions: a case series (with video). Surg Endosc 2022; 36:8231-8236. [PMID: 35511341 DOI: 10.1007/s00464-022-09266-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is the treatment of choice for colorectal neoplasms in Japan. ESD can completely peel off the lesion and is associated with a significantly lower recurrence rate of colorectal cancers than EMR and is widely used to treat gastrointestinal tumors. This study aimed to evaluate in vivo traction in endoscopic submucosal dissection (ESD) of proximal colon lesions. METHODS This retrospective study included patients with lesions in the proximal colon who received ESD treatment at Qilu Hospital of Shandong University from June 2018 to December 2020. Patients were divided into two groups according to the in vivo traction method (orthodontic ring or elastic ring) during operation. The operation time, dissection time, proportion of complete resection of lesions, and complications were compared between the two groups. RESULTS There were 28 patients in this study. In the orthodontic ring group (n = 10), the average lesion diameter was 2.0-2.5 cm, and the average operation and dissection times were 26.5 ± 7.47 and 21.5 ± 7.47 min, respectively. In the elastic ring group (n = 18), the average lesion diameter was 2.5-5.5 cm, and the average operation and dissection times were 27.39 ± 11.83 and 22.39 ± 11.83 min, respectively. All lesions were completely resected in a single operation, and no wound perforation and delayed bleeding occurred. CONCLUSION In vivo traction-assisted ESD can be used to resect proximal colon lesions in selected patients (precancerous lesions and early colon cancer limited to the mucosa or with a submucosa infiltration depth of < 1000 µm).
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Ramírez-Ramírez M, Zamorano-Orozco Y, Beltrán-Campos E. Simplified magnetic anchor-guided endoscopic submucosal dissection: an ex vivo porcine model. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2022; 87:13-19. [DOI: 10.1016/j.rgmxen.2021.03.002] [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: 06/23/2020] [Accepted: 09/02/2020] [Indexed: 12/01/2022] Open
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De Luca L, Di Berardino M, Mangiavillano B, Repici A. Gastric endoscopic submucosal dissection in Western countries: Indications, applications, efficacy and training perspective. World J Gastrointest Surg 2021; 13:1180-1189. [PMID: 34754386 PMCID: PMC8554716 DOI: 10.4240/wjgs.v13.i10.1180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/02/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection was introduced in Japan for the mini-invasive treatment of early gastric cancer, as part of national screening program considering high prevalence of disease in these latitudes. This technique allows en-bloc curative oncological excision and to obtain in a single step R0-resection, characterization, histological staging and potential cure of the tumor with a very high cost-benefit balance. Over the years, Western endoscopists have adopted endoscopic submucosal dissection, achieving good rates of efficacy, long-term improved outcomes and safety, with low risk of local recurrence comparable to those obtained in Asian institutes. However, according to some authors, the excellent outcomes from East country could not be representative of the Western experience. Despite epidemiological differences of early gastric cancer, scant volume data and limitations in training opportunities between Western and Eastern countries, European Society of Gastrointestinal Endoscopy have adopted Japanese guidelines and developed a European core curriculum for endoscopic submucosal dissection training. Endoscopists should be able to estimate the probability of performing a curative resection by considering the benefit/risk relationship case-by-case in order to implement a correct decision-making process.
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Affiliation(s)
- Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Riuniti Marche North Hospital, Pesaro 61121, Italy
| | | | | | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Humanitas University, Rozzano 20089, Italy
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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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Ramírez-Ramírez MÁ, Zamorano-Orozco Y, Beltrán-Campos EG. Simplified magnetic anchor-guided endoscopic submucosal dissection: an ex vivo porcine model. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 87:S0375-0906(20)30137-3. [PMID: 33516586 DOI: 10.1016/j.rgmx.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/13/2020] [Accepted: 09/02/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION AND AIMS Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. MATERIALS AND METHODS An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. RESULTS A total of 15 en bloc ESDs (five with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90 min. Lesion size ranged from 15 to 50 mm (mean 30 mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). CONCLUSIONS Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.
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Affiliation(s)
- M Á Ramírez-Ramírez
- Departamento de Endoscopia, Hospital Regional Número 1 «Carlos Macgregor Sánchez Navarro» del Instituto Mexicano del Seguro Social, Ciudad de México, México.
| | - Y Zamorano-Orozco
- Departamento de Endoscopia, Hospital Regional Número 1 «Carlos Macgregor Sánchez Navarro» del Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - E G Beltrán-Campos
- Departamento de Endoscopia, Hospital Regional Número 1 «Carlos Macgregor Sánchez Navarro» del Instituto Mexicano del Seguro Social, Ciudad de México, México
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Double-clip traction could be superior to the pocket-creation method with cylindrical cap for colonic ESD: a randomized study in an ex vivo model. Surg Endosc 2021; 35:1482-1491. [PMID: 33398562 DOI: 10.1007/s00464-020-08171-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/15/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION In Western countries, debates between ESD vs piece-meal EMR as the best treatment for large colorectal adenomas persist regarding the difficulty of ESD the colon, and the safety and relatively good results of piece-meal endoscopic mucosal resection (EMR). Pocket-creation method (PCM) and double-clip countertraction (DCT) are two strategies recently published to facilitate ESD in this challenging situation. METHOD This is a randomized animal study to compare PCM and DCT strategies for colonic ESD on ex vivo models (bovine colon) performed by 3 operators novice in ESD. Hybridknife type T was used to inject normal saline tinted with a small amount of blue dye in all procedures. Randomization was stratified according to the use of gravity assist. Primary endpoint was the difference in resection speed between PCM and DCT strategies. RESULTS Resection speed was significantly higher in the DCT group than in the PCM group (56.3 vs. 31.6 mm2/min, p = 0.01). Technical success rate, defined as en bloc resection in under 60 min, was significantly better in the DCT group than in the PCM group (100% vs. 84.4%, p = 0.024), perforation rate was lower (0% vs. 18.8%, p = 0.012), and difficulty score was better (2.4 vs. 6.2, p < 0.0001) as was procedure duration (24.2 vs. 40.2 min, p < 0.0001). CONCLUSION DCT was superior to PCM for ESD in our validated bovine colon model. This strategy is inexpensive, easy to use and adaptive. It might facilitate the widespread use of colonic ESD in Western countries and change Western ideas regarding the use of colonic ESD compared with piece-meal EMR for large benign lesions.
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Tachikawa J, Chiba H, Arimoto J, Kuwabara H, Nakaoka M. Endoscopic submucosal tunnel dissection with ring-thread countertraction for a large gastric tumor with extensive severe fibrosis. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2021; 6:11-13. [PMID: 33490745 PMCID: PMC7805125 DOI: 10.1016/j.vgie.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Jun Tachikawa
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
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Liu YZ, Lv XH, Deng K, Yang JL. Efficacy and safety of endoscopic submucosal tunnel dissection vs endoscopic submucosal dissection for early superficial upper gastrointestinal precancerous lesions and tumors: A meta-analysis. J Dig Dis 2020; 21:480-489. [PMID: 32579253 DOI: 10.1111/1751-2980.12915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/03/2020] [Accepted: 06/21/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Endoscopic submucosal tunnel dissection (ESTD) is a new treatment for superficial upper gastrointestinal precancerous lesions and tumors. However, its safety and efficacy for treating these lesions is still uncertain. This meta-analysis aimed to compare the efficacy and safety of ESTD with those of endoscopic submucosal dissection (ESD) in treating early superficial upper gastrointestinal precancerous lesions and tumors. METHODS Electronic databases, including EMBASE, PubMed, Cochrane Library and the Web of Science, were systematically searched for articles published up to 1 April 2020. The primary outcomes were complete and en bloc resection rates of the lesions. The secondary outcomes included operation time, speed of dissection, complication and recurrence rates. The Newcastle-Ottawa quality assessment scale was used to evaluate the quality of the studies. RESULTS Seven studies were included in the final meta-analysis. The complete and en bloc resection rates of early superficial esophageal lesions as well as the en bloc resection rate of early superficial gastric lesions were similar between the ESTD and ESD groups. Compared with the ESD group, the ESTD group had a higher en bloc resection rate for early superficial gastric lesions. A faster dissection speed was observed in both superficial esophageal and gastric lesions. In gastric lesions, the operation time of the ESTD group was shorter than that of the ESD group, while it did not differ for esophageal lesions. There were no obvious differences in bleeding and perforation rates between the groups. CONCLUSION As an endoscopic technique for treating early superficial upper gastrointestinal lesions, ESTD is as safe as and more effective than ESD, especially for gastric lesions.
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Affiliation(s)
- Yu Zhi Liu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xiu He Lv
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Kai Deng
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jin Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Nagata M. Internal traction method using a spring-and-loop with clip (S-O clip) allows countertraction in gastric endoscopic submucosal dissection. Surg Endosc 2020; 34:3722-3733. [PMID: 32350668 PMCID: PMC7326859 DOI: 10.1007/s00464-020-07590-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Insufficient countertraction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Internal traction method using a spring-and-loop with clip (SLC) allows sufficient traction in any direction and good field of vision. However, the attachment procedure is difficult and interference with the endoscope can occur in the retroflexed endoscopic position. We have developed a new use of SLC that simplifies the attachment procedure, eliminating interference with the endoscope. The aim of this study was to investigate the efficacy of SLC for gastric ESD. METHODS We retrospectively recruited 140 patients with gastric neoplasms who underwent ESD between November 2015 and October 2018 at our department. Among them, 51 patients treated using SLC-assisted ESD (SLC-ESD) and 89 patients treated using conventional ESD (C-ESD) were compared. Propensity score matching was performed to compensate for the differences in age, sex, lesion location, lesion position, specimen size, and ulcer findings. The primary outcome was ESD procedure time. RESULTS Propensity score matching generated 51 matched pairs. The procedure time in the SLC-ESD group was significantly shorter than that in the C-ESD group (median [interquartile], 40.0 [27.0-81.5] minutes versus 69.0 [46.5-113.5] minutes, P = 0.008). The mean SLC attachment time was 2.08 min. There were no significant differences in complete en bloc resection rate between SLC-ESD and C-ESD groups (100% versus 96.1%, P = 0.495). There were not perforation cases in either group. CONCLUSIONS SLC may offer an efficient method for gastric ESD, with a short attachment procedure time.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, 1-5-1, Tsujidoukandai, Fujisawa-shi, Kanagawa, Japan.
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Abstract
PURPOSE OF REVIEW To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). RECENT FINDINGS EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.
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Affiliation(s)
- Yahya Ahmed
- Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed Othman
- Baylor St Luke's Medical Center, Houston, TX, USA. .,Division of Gastroenterology, Baylor College of Medicine, 7200 Cambridge St., 8th Floor, Suite 8B, Houston, TX, 77030, USA.
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Matsumoto K, Konuma H, Ueyama H, Komori H, Akazawa Y, Ueyama M, Takeda T, Matsumoto K, Asaoka D, Hojo M, Yao T, Nagahara A. Multibending scope use for reduction of perforation risks in endoscopic submucosal dissection. MINIM INVASIV THER 2020; 30:72-80. [PMID: 32108547 DOI: 10.1080/13645706.2019.1688352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS To identify areas that are difficult to access by the single scope at the time of endoscopic submucosal dissection (ESD) and examine the effectiveness, en-bloc, R0 resection, and perforation rate after changing to multibending scope at the same site. MATERIAL AND METHODS When the direct visualization of the submucosal layer became impossible with Q260J or in the position where the device became vertical and peeling became impossible in parallel, we decided to change to the multibending 2TQ260M scope to record the position where the change was effective and the perforation rate. RESULTS A total of 315 lesions were studied. Of the 12 sites, ESD was completed using the Q260J alone at four sites. The 2TQ260M scope was used with greater frequency at the fornix (88.9%) and on the line of the lesser curvature of the stomach (37.1%). In the cases with observed perforations (0.9%), the submucosal layer was not elevated due to the adhesion caused by strong fibrosis. None of the cases involving the change to 2TQ260M was ineffective, nor were perforations observed, and all resected specimens were en-bloc and R0 resections. CONCLUSIONS The success rate of this scope may help clinicians perform ESD with greater understanding.
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Affiliation(s)
- Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hironori Konuma
- Department of Gastroenterology, Juntendo Nerima Hospital, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Komori
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoichi Akazawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Misuzu Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeda
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kohei Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Daisuke Asaoka
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Mariko Hojo
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Yao
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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An internal magnet traction device reduces procedure time for endoscopic submucosal dissection by expert and non-expert endoscopists: ex vivo study in a porcine colorectal model (with video). Surg Endosc 2019; 33:2696-2703. [PMID: 31069502 DOI: 10.1007/s00464-019-06817-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/30/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Efficacy of an internal magnet traction device (MTD) for gastric endoscopic submucosal dissection (ESD) by an expert endoscopist has been reported. We hypothesized that use of the MTD would enhance the performance of colorectal ESD in a non-expert endoscopist in ESD compared to the conventional technique. Primary aim of this study was to compare procedure times between conventional ESD (C-ESD) and MTD-assisted ESD (MTD-ESD) by expert and non-expert endoscopists in ESD. Secondary aims included rate of en bloc resection, iatrogenic injury, visualization score of the submucosal layer, and endoscopist satisfaction score. METHODS A total of 56 lesions were created in an ex vivo porcine colorectum. Two endoscopists completed C-ESD (n = 28) and MTD-ESD (n = 28). Lesions measured 3 cm in diameter and were located on either the anterior or posterior colorectal wall. The MTD consisted of a small neodymium magnet and nylon monofilament attached to a through-the-scope clip. The first MTD was deployed on the opposing colorectal wall of the target lesion and a second MTD was then deployed directly onto the distal margin of the lesion. RESULTS Total procedure time for MTD-ESD was significantly shorter than C-ESD for both expert (median: 15.8 vs. 19.3 min, p < 0.05) and non-expert (median: 21.3 vs. 33.9 min, p < 0.001) endoscopists. All lesions were resected en bloc. There was no iatrogenic muscularis propria injury in the MTD-ESD group. For both the expert and non-expert, scores for MTD-ESD were significantly higher for submucosal layer visualization (p < 0.05) and endoscopist satisfaction (p < 0.001) compared to C-ESD. CONCLUSIONS Use of the MTD significantly reduced procedure time for both expert and non-expert endoscopists performing ESD. Improving the efficiency, safety, and satisfaction of ESD with such a device particularly for non-expert endoscopists is appealing and could potentially minimize the complexity and duration of the procedure allowing for more widespread use of the technique.
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Suture pulley countertraction method reduces procedure time and technical demand of endoscopic submucosal dissection among novice endoscopists learning endoscopic submucosal dissection: a prospective randomized ex vivo study. Gastrointest Endosc 2019; 89:177-184. [PMID: 30148993 DOI: 10.1016/j.gie.2018.08.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The lack of reliable countertraction in endoscopic submucosal dissection (ESD) contributes to its technical demand and increased procedure time. We aimed to prospectively evaluate the efficacy of the suture pulley countertraction method in endoscopists new to both suturing and ESD. METHODS Two 30-mm circular lesions were created in an ex vivo porcine stomach model. Endoscopists considered novices for both endoscopic suturing and ESD were randomized to either traditional or suture pulley ESD first and performed ESD using each technique. Procedure time was recorded including time of circumferential incision, suture pulley placement, and submucosal dissection. After completion of each ESD, participants graded the difficulty of the procedure using the National Aeronautical and Space Administration (NASA) Task Load Index. RESULTS Thirteen participants (8 fellows, 5 attendings) completed the study using both methods. Mean total procedure time was shorter using suture pulley ESD compared with traditional ESD (26.7 ± 7.3 vs 59.4 ± 20.4 minutes, P < .001). The suture pulley required a mean 6.2 ± 2.1 minutes to place. Submucosal dissection time was shorter using suture pulley ESD compared with traditional ESD (8.4 ± 2.9 vs 47.2 ± 16.3 minutes, P < .001). All 7 individual indices and total score on the NASA Task Load Index were significantly improved using the suture pulley ESD method (P < .001). CONCLUSIONS The suture pulley countertraction method significantly decreases procedure time and technical demand of ESD among endoscopists at all skill levels who are new to ESD. The results of this study have potential implications for ESD training in the United States.
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Matsuzaki I, Hattori M, Hirose K, Esaki M, Yoshikawa M, Yokoi T, Kobayashi M, Miyahara R, Hirooka Y, Goto H. Magnetic anchor-guided endoscopic submucosal dissection for gastric lesions (with video). Gastrointest Endosc 2018; 87:1576-1580. [PMID: 29352971 DOI: 10.1016/j.gie.2018.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/10/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The feasibility of magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD) using a neodymium magnet for gastric lesions has not been clarified. The aim of study was to evaluate the feasibility of MAG-ESD using neodymium magnets while treating gastric lesions. METHODS This prospective trial was conducted at the Yamashita Hospital. MAG-ESD was performed for 50 gastric lesions using an insulated-tip knife. The magnetic anchor consisted of an internal neodymium magnet attached to a hemoclip with 3-0 silk. The external and internal magnets were made from the neodymium magnet. The feasibility of traction using MAG-ESD, en bloc resection rate, complete en bloc resection rate, time required for preparation and attaching the magnetic anchor, procedure time, rate of retrieval of the magnetic anchors, and adverse events were evaluated. RESULTS Fifty patients (median lesion size, 20 mm [range, 5-100]) were enrolled. MAG-ESDs were successfully performed for all 50 gastric lesions. Adequate counter-traction was obtained using the external magnet. En bloc resections were achieved and complete en bloc resections confirmed in all cases without adverse events. Attaching the magnetic anchor required a median of 6 minutes (range, 2-14). The median procedure time was 49 minutes (range, 15-301), and the magnetic anchors could be retrieved in all cases. CONCLUSIONS This study clearly demonstrated the feasibility of this MAG-ESD in the stomach. We hope this procedure will facilitate the resection of difficult lesions. (Clinical trial registration number: UMIN000024100.).
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Affiliation(s)
- Ippei Matsuzaki
- Department of Gastroenterology, Yamashita Hospital, Ichinomiya, Japan
| | - Masashi Hattori
- Department of Gastroenterology, Yamashita Hospital, Ichinomiya, Japan
| | - Ken Hirose
- Department of Gastroenterology, Yamashita Hospital, Ichinomiya, Japan
| | - Masaya Esaki
- Department of Gastroenterology, Yamashita Hospital, Ichinomiya, Japan
| | | | - Takio Yokoi
- Department of Pathology, Yamashita Hospital, Ichinomiya, Japan
| | - Makoto Kobayashi
- Department of Gastroenterology, Yokkaichi Municipal Hospital, Mie, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Sharma SK, Hiratsuka T, Hara H, Milsom JW. Antigravity ESD - double-balloon-assisted underwater with traction hybrid technique. Endosc Int Open 2018; 6:E739-E744. [PMID: 29876511 PMCID: PMC5988544 DOI: 10.1055/a-0578-8081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 02/05/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Complex colorectal polyps or those positioned in difficult anatomic locations are an endoscopic therapeutic challenge. Underwater endoscopic submucosal dissection (UESD) is a potential technical solution to facilitate efficient polyp removal. In addition, endoscopic tissue retraction has been confined to limited methods of varying efficacy and complexity. The aim of this study was to evaluate the efficiency of a unique UESD technique for removing complex polyps using double-balloon-assisted retraction (R). MATERIALS AND METHODS Using fresh ex-vivo porcine rectum, 4-cm polyps were created using electrosurgery and positioned at "6 o'clock" within an established ESD model. Six resections were performed in each group. Underwater techniques were facilitated using a novel double-balloon platform (Dilumen, Lumendi, Westport, Connecticut, United States). RESULTS UESD-R had a significantly shorter total procedural time than cap-assisted ESD and UESD alone (24 vs. 58 vs. 56 mins). UESD-R produced a dissection time on average of 5 minutes, attributed to the retraction provided. There was also a subjective significant reduction in electrosurgical smoke with the underwater techniques contributing to improved visualization. CONCLUSIONS Here we report the first ex-vivo experience of a unique double-balloon endoscopic platform optimized for UESD with tissue traction capability. UESD-R removed complex lesions in significantly shorter time than conventional means. The combined benefits of UESD and retraction appeared to be additive when tackling complex polyps and should be studied further.
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Affiliation(s)
- Sam K. Sharma
- Minimally Invasive New Technologies, Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States,Corresponding author Sam K. Sharma Minimally Invasive New TechnologiesDepartment of Surgery, Weill Cornell Medicine, New York Presbyterian HospitalNew York, New YorkUnited States212-746-8750
| | - Takahiro Hiratsuka
- Minimally Invasive New Technologies, Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Hisashi Hara
- Minimally Invasive New Technologies, Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Jeffrey W. Milsom
- Minimally Invasive New Technologies, Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
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Endoscopic Submucosal Tunnel Dissection for Large Gastric Neoplastic Lesions: A Case-Matched Controlled Study. Gastroenterol Res Pract 2018; 2018:1419369. [PMID: 29692806 PMCID: PMC5859796 DOI: 10.1155/2018/1419369] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 02/04/2018] [Indexed: 12/12/2022] Open
Abstract
Aim To evaluate the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) for resection of large superficial gastric lesions (SGLs). Methods The clinicopathological records of patients performed with ESTD or endoscopic submucosal dissection (ESD) for SGLs between January 2012 and January 2014 were retrospectively reviewed. 7 cases undergoing ESTD were enrolled to form the ESTD group. The cases were individually matched at a 1 : 1 ratio to other patients performed with ESD according to lesion location, ulcer or scar findings, resected specimen area, operation time and operators, and the matched cases constituting the ESD group. The treatment outcomes were compared between the two groups. Results The mean specimen size was 46 mm. 10 lesions were located in the cardia and 4 lesions in the lesser curvature of the lower gastric body. En bloc resection was achieved for all lesions. The mean ESTD resection time was 69 minutes as against 87.7 minutes for the ESD (P = 0.01). The mean resection speed was faster for ESTD than for ESD (18.86 mm2/min versus 13.76 mm2/min, P = 0.03). There were no significant differences regarding the safety and curability during the endoscopic follow-up (mean 27 months). Conclusions ESTD is effective and safe for the removal of SGLs and appears to be an optimal option for patients with large SGLs at suitable sites.
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Jacques J, Legros R, Rivory J, Charissoux A, Sautereau D, Ponchon T, Pioche M. The "tunnel + clip" strategy standardised and facilitates oesophageal ESD procedures: a prospective, consecutive bi-centric study. Surg Endosc 2017; 31:4838-4847. [PMID: 28378087 DOI: 10.1007/s00464-017-5514-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/08/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION ESD is the treatment of choice for superficial neoplasms of the oesophagus; ESD is oncologically efficient and associated with less morbidity than the surgical alternative. ESD requires a high level of skill, being both technically challenging and time consuming. Therefore, ESD is often reserved for experts. A combination of a tunnel technique with clip-line traction may enable optimisation of oesophageal ESD. PATIENTS AND METHODS From January 2015 to December 2016, we performed a prospective two-centre case study of consecutive "tunnel + clip" oesophageal ESD. Four young operators (each of whom had performed fewer than 50 ESDs and fewer than five oesophageal ESDs) treated patients requiring ESD using the tunnel + clip method. This involves generation of a classic tunnel beneath the lesion, with constant traction being applied by a clip with a line placed at the oral side of the tunnel. RESULTS Sixty-two lesions (25 SCCs and 34 ADK/HGDs complicating Barrett's oesophagus) were consecutively resected. The en bloc, R0, and curative resection rates were 100% (62/62), 88.7% (55/62), and 74.2% (46/62), respectively. No perforation was noted. The mean ESD velocity was 24.5 mm2/min for lesions of mean length 59.6 mm. The tunnel + clip approach greatly aided the procedure. No pathological damage caused by clipping was evident. CONCLUSION Use of the tunnel + clip strategy to treat oesophageal ESD is effective and safe, even when performed by physicians with little prior experience. It is thus possible to standardise ESD of superficial oesophageal neoplasms and increase the velocity of dissection. Our procedure will encourage the use of oesophageal ESD in Western countries.
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Affiliation(s)
- Jérémie Jacques
- Service d'hépato-gastro-entérologie, CHU Dupuytren, 2 avenue Martin Luther-King, 87042, Limoges, France.
| | - Romain Legros
- Service d'hépato-gastro-entérologie, CHU Dupuytren, 2 avenue Martin Luther-King, 87042, Limoges, France
| | - Jérome Rivory
- Service d'hépato-gastro-entérologie, Hôpital Edouard Herriot, Hospices civils de lyon, 5 place d'Arsonval, 69003, Lyon, France
| | - Aurélie Charissoux
- Service d'anatomopathologie, CHU Dupuytren, 2 avenue Martin Luther-King, 87042, Limoges, France
| | - Denis Sautereau
- Service d'hépato-gastro-entérologie, CHU Dupuytren, 2 avenue Martin Luther-King, 87042, Limoges, France
| | - Thierry Ponchon
- Service d'hépato-gastro-entérologie, Hôpital Edouard Herriot, Hospices civils de lyon, 5 place d'Arsonval, 69003, Lyon, France
| | - Mathieu Pioche
- Service d'hépato-gastro-entérologie, Hôpital Edouard Herriot, Hospices civils de lyon, 5 place d'Arsonval, 69003, Lyon, France
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Tsuji K, Yoshida N, Nakanishi H, Takemura K, Yamada S, Doyama H. Recent traction methods for endoscopic submucosal dissection. World J Gastroenterol 2016; 22:5917-5926. [PMID: 27468186 PMCID: PMC4948268 DOI: 10.3748/wjg.v22.i26.5917] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/05/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Endoscopic mucosal resection (EMR) is problematic with regard to en bloc and curable resection rates. Advancements in endoscopic techniques have enabled novel endoscopic approaches such as endoscopic submucosal dissection (ESD), which has overcome some EMR problems, and has become the standard treatment for gastrointestinal tumors. However, ESD is technically difficult. Procedure time is longer and complications such as intraoperative perforation and bleeding occur more frequently than in EMR. Recently various traction methods have been introduced to facilitate ESD procedures, such as clip with line, external forceps, clip and snare, internal traction, double scope, and magnetic anchor. Each method must be used appropriately according to the anatomical characteristics. In this review we discuss recently proposed traction methods for ESD based on the characteristics of various anatomical sites.
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Yoshida N, Doyama H, Ota R, Takeda Y, Nakanishi H, Tominaga K, Tsuji S, Takemura K. Effectiveness of clip-and-snare method using pre-looping technique for gastric endoscopic submucosal dissection. World J Gastrointest Endosc 2016; 8:451-457. [PMID: 27358671 PMCID: PMC4919694 DOI: 10.4253/wjge.v8.i12.451] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/06/2016] [Accepted: 05/09/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate efficacy and safety of clip-and-snare method using pre-looping technique (CSM-PLT) for gastric endoscopic submucosal dissection (ESD).
METHODS: In the CSM-PLT method, a clip attached to the lesion side was strangulated with a snare, followed by application of an appropriate tension to the lesion independent of an endoscope. Twenty consecutive lesions were resected by ESD using CSM-PLT (CSM-PLT group) and compared with a control group, including 20 lesions that were resected by conventional ESD. The control group was matched based on the size and location of the lesion, presence of pathologic fibrosis, and experience of endoscopists. Total procedure time of ESD, proportion of en bloc resection, and complications were analyzed.
RESULTS: The total procedure time for the CSM-PLT group was significantly shorter than that for the control group (38.5 min vs 59.5 min, P = 0.023); all lesions were resected en bloc by ESD. There was no significant difference in complications between the two groups. Moreover, there was no complication in the CSM-PLT group. In one large lesion (size: 74 mm) that underwent extensive CSM-PLT during ESD, we used an additional CSM-PLT on another edge of the lesion after achieving submucosal resection to the maximum extent possible during initial CSM-PLT. In two lesions, the snare came off the lesion together with the clip after a sudden pull; nevertheless, ESD was successful in all lesions.
CONCLUSION: CSM-PLT was an effective and safe method for gastric ESD.
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Zhai YQ, Li HK, Linghu EQ. Endoscopic submucosal tunnel dissection for large superficial esophageal squamous cell neoplasms. World J Gastroenterol 2016; 22:435-445. [PMID: 26755889 PMCID: PMC4698506 DOI: 10.3748/wjg.v22.i1.435] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/30/2015] [Accepted: 09/15/2015] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial esophageal squamous cell neoplasms (SESCNs) with no risk of lymphatic metastasis. However, for large SESCNs, especially when exceeding two-thirds of the esophageal circumference, conventional ESD is time-consuming and has an increased risk of adverse events. Based on the submucosal tunnel conception, endoscopic submucosal tunnel dissection (ESTD) was first introduced by us to remove large SESCNs, with excellent results. Studies from different centers also reported favorable results. Compared with conventional ESD, ESTD has a more rapid dissection speed and R0 resection rate. Currently in China, ESTD for large SESCNs is an important part of the digestive endoscopic tunnel technique, as is peroral endoscopic myotomy for achalasia and submucosal tunnel endoscopic resection for submucosal tumors of the muscularis propria. However, not all patients with SESCNs are candidates for ESTD, and postoperative esophageal strictures should also be taken into consideration, especially for lesions with a circumference greater than three-quarters. In this article, we describe our experience, review the literature of ESTD, and provide detailed information on indications, standard procedures, outcomes, and complications of ESTD.
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Matsuzaki I, Miyahara R, Hirooka Y, Funasaka K, Furukawa K, Ohno E, Nakamura M, Kawashima H, Maeda O, Watanabe O, Ando T, Kobayashi M, Goto H. Simplified magnetic anchor-guided endoscopic submucosal dissection in dogs (with videos). Gastrointest Endosc 2014; 80:712-716. [PMID: 25085334 DOI: 10.1016/j.gie.2014.05.334] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/03/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD) was developed to reduce adverse events such as bleeding and perforation and to facilitate ESD. However, the external electromagnet required miniaturization to make it suitable for daily clinical practice. OBJECTIVE To evaluate the feasibility of simplified MAG-ESD using permanent magnets. DESIGN Case series. SETTING Nagoya University Hospital. SUBJECTS Beagle dogs. INTERVENTIONS The simplified MAG-ESD was performed on 10 representative areas of the stomachs of beagle dogs. The magnetic anchor consisted of an internal magnet attached to a hemoclip. The external and internal magnets were made from the rare earth neodymium. MAIN OUTCOME MEASUREMENTS The feasibility of countertraction with good visualization using simplified MAG-ESD. The rate of perforation, the time required for preparation, and attaching the magnetic anchor were also evaluated. RESULTS All lesions were successfully resected without perforation. The magnetic anchor could be controlled easily, and direct visualization was maintained by adequate counter traction. Preparing the magnetic anchor and grasping the mucosal edge using the hemoclip was easy and required a median of only 4 minutes (range, 2-7 minutes). LIMITATIONS Animal experiment, low number and lesion size. CONCLUSIONS This simplified MAG-ESD is feasible and allowed excellent visualization in the dog stomach. The feasibility of this system should be assessed in humans.
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Affiliation(s)
- Ippei Matsuzaki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kohei Funasaka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Osamu Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Osamu Watanabe
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takafumi Ando
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Makoto Kobayashi
- Department of Gastroenterology, Yokkaichi Municipal Hospital, Mie, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
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Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video). Gastrointest Endosc 2014; 80:495-502. [PMID: 24679655 PMCID: PMC4426966 DOI: 10.1016/j.gie.2014.01.050] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/29/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear. OBJECTIVE To objectively analyze efficacy of countertraction using the suture-pulley method for ESD. DESIGN Prospective ex vivo animal study. SETTING Animal laboratory. INTERVENTIONS Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley. MAIN OUTCOME MEASUREMENTS The primary outcome of this study was total procedure time. RESULTS The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median, 25% to 75%, interquartile range [IQR]: 531 seconds [474.3-549.3 seconds] vs 845 seconds [656.3-1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0-168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median, 1601 seconds; IQR, 1547.5-1708.8 seconds vs median, 663 seconds; IQR, 627.5-681.8 seconds; P = .01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index. LIMITATIONS Ex vivo study. CONCLUSIONS The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.
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Aihara H, Ryou M, Kumar N, Ryan M, Thompson C. A novel magnetic countertraction device for endoscopic submucosal dissection significantly reduces procedure time and minimizes technical difficulty. Endoscopy 2014; 46:422-5. [PMID: 24573770 PMCID: PMC5019105 DOI: 10.1055/s-0034-1364940] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS In endoscopic submucosal dissection (ESD), effective countertraction may overcome the current drawbacks of longer procedure times and increased technical demands. The objective of this study was to compare the efficacy of ESD using a novel magnetic countertraction device with that of the traditional technique. METHODS Each ESD was performed on simulated gastric lesions of 30 mm diameter created at five different locations. In total, 10 ESDs were performed using this novel device and 10 were performed by the standard technique. RESULTS The magnetic countertraction device allowed directional tissue manipulation and exposure of the submucosal space. The total procedure time was 605 ± 303.7 seconds in the countertraction group vs. 1082 ± 515.9 seconds in the control group (P = 0.021). CONCLUSIONS This study demonstrated that using a novel magnetic countertraction device during ESD is technically feasible and enables the operator to dynamically manipulate countertraction such that the submucosal layer is visualized directly. Use of this device significantly reduced procedure time compared with conventional ESD techniques.
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Affiliation(s)
- Hiroyuki Aihara
- Developmental Endoscopy, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Marvin Ryou
- Developmental Endoscopy, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Nitin Kumar
- Developmental Endoscopy, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Michele Ryan
- Developmental Endoscopy, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Christopher Thompson
- Developmental Endoscopy, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Chung H, Dhumane P, Liu KH, Donatelli G, Dallemagne B, Marescaux J. Endoscopic submucosal dissection with a novel traction method using a steerable grasper: a feasibility study in a porcine model. Surg Innov 2013; 21:5-10. [PMID: 23938360 DOI: 10.1177/1553350613495980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a technically challenging procedure in which complications and operative times depend on the operator's expertise as well as on the location and size of the lesion. Good visualization of the submucosal dissection plane is essential to perform a safe and effective ESD. OBJECTIVES To evaluate the feasibility, efficacy, and safety of a novel traction method using an over-the-scope steerable grasper to improve the exposure of the dissection plane during gastric ESD. RESULTS A total of 24 ESDs were performed without any complications in various locations of porcine stomachs, including antrum, gastric body, and cardia. En bloc complete resections were achieved in all cases. The mean specimen size was 44.92 ± 8.30 mm, mean total procedure time was 29.17 ± 11.27 minutes, and mean dissection time was 15.08 ± 7.21 minutes. The optimal dissection plane could be obtained by controlling the grasper in all cases. CONCLUSIONS Technical feasibility, efficacy, and safety of the over-the-scope steerable grasper technique were demonstrated in order to provide dynamic and controlled traction during ESD at different locations of porcine stomachs.
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Affiliation(s)
- Hyunsoo Chung
- 1IRCAD, University of Strasbourg, Strasbourg, France
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Matsumoto K, Nagahara A, Ueyama H, Konuma H, Morimoto T, Sasaki H, Hayashi T, Shibuya T, Sakamoto N, Osada T, Ogihara T, Yao T, Watanabe S. Development and clinical usability of a new traction device "medical ring" for endoscopic submucosal dissection of early gastric cancer. Surg Endosc 2013; 27:3444-51. [PMID: 23525882 PMCID: PMC3751377 DOI: 10.1007/s00464-013-2887-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 02/15/2013] [Indexed: 12/19/2022]
Abstract
Background Although various traction devices exist for endoscopic submucosal dissection (ESD), the effects of the material used in the devices on the human body has not been considered. Moreover, there has been no report on a device that facilitates dissection both on the oral and anal side of the lesion. We made a traction device that has no deleterious effects on the body and is noninvasive, easy to use, and enables a bilateral approach in ESD. We report the process of its creation and a prospective evaluation of its usage in actual ESD procedures. Methods This study is prospective case control study. Thirty-seven patients for whom the device would be used were consecutively and prospectively enrolled (device used group). Control subjects in whom the device would not be used and who had lesions matched for size and location with those of the device used group were randomly selected (device not used group). Both groups were classified into three subgroups according to treatment difficulty: group A: easy; group B: intermediate; and group C: difficult. The dissection time per cm2 in each group was examined. Results Dissection times in the device not used group/device used group were as follows: group A, 5.8/2.1 min/cm2 (p < 0.01); group B, 6.1/3.8 min/cm2 (p < 0.05); and group C, 7.9/3.6 min/cm2 (p < 0.01), respectively. Conclusions The newly developed medical ring was shown to be feasible and safe and allowed excellent visualization through suitable tension and facilitated rapid gastric ESD. Electronic supplementary material The online version of this article (doi:10.1007/s00464-013-2887-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Hironori Konuma
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Takasi Morimoto
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Hitoshi Sasaki
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Takuo Hayashi
- Department of Human Pathology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Taro Osada
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Tatsuo Ogihara
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Takashi Yao
- Department of Human Pathology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Sumio Watanabe
- Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
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Oyama T. Counter traction makes endoscopic submucosal dissection easier. Clin Endosc 2012; 45:375-8. [PMID: 23251884 PMCID: PMC3521938 DOI: 10.5946/ce.2012.45.4.375] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/11/2012] [Accepted: 10/14/2012] [Indexed: 12/11/2022] Open
Abstract
Poor counter traction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Good counter traction allows dissections to be performed more quickly and safely. Position change, which utilizes gravity, is the simplest method to create a clear field of vision. It is useful especially for esophageal and colon ESD. The second easiest method is clip with line method. Counter traction made by clip with line accomplishes the creation of a clear field of vision and suitable counter traction thereby making ESD more efficient and safe. The author published this method in 2002. The name ESD was not established in those days; the name cutting endoscopic mucosal resection (EMR) or EMR with hook knife was used. The other traction methods such as external grasping forceps, internal traction, double channel scope, and double scopes method are introduced in this paper. A good strategy for creating counter traction makes ESD easier.
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Affiliation(s)
- Tsuneo Oyama
- Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
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28
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Ex vivo comparative study using the Endolifter® as a traction device for enhancing submucosal visualization during endoscopic submucosal dissection. Surg Endosc 2012; 27:1422-7. [PMID: 23093235 DOI: 10.1007/s00464-012-2583-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 09/17/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a technically demanding procedure, and exposure of the submucosa depends on the action of gravity and submucosal injection. The aim of the study was to investigate the effectiveness of the Endolifter(®) as a traction device for enhancing submucosal visualization during ESD. METHODS This was a prospective ex vivo comparative study conducted between September 2010 and March 2011 in the Prince of Wales Hospital. Consecutive ESDs were performed by four experienced endoscopists in an ex vivo ESD model with or without the Endolifter(®). The Endolifter(®) allows simultaneous grasping, retracting and lifting of the mucosa during ESD, resulting in exposure of the submucosa. Each of the procedures were recorded and reviewed later by two independent assessors. The outcome measures included the proportion of time that the submucosa was visualized during the procedures (SM ratio), procedural times, perforation rates, amount of submucosal injections, and the difficulty of the procedure. RESULTS Forty-eight gastric ESD procedures were performed on the model. The SM ratio was higher in the Endolifter(®) group (P = 0.007), particularly for lesions located at the antrum (P < 0.001). The time required for submucosal dissection and the total procedural time were also less in the Endolifter(®) group. The endoscopists rated the ESD procedures in the Endolifter(®) group as less difficult (P = 0.033). CONCLUSIONS The Endolifter(®) improved submucosal visualization during gastric ESD and reduces the difficulty of performing the procedures. The device may improve the ease of performing ESD in low-volume centers or large mucosal lesions.
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Sakurazawa N, Kato S, Fujita I, Kanazawa Y, Onodera H, Uchida E. Supportive techniques and devices for endoscopic submucosal dissection of gastric cancer. World J Gastrointest Endosc 2012; 4:231-5. [PMID: 22720124 PMCID: PMC3377865 DOI: 10.4253/wjge.v4.i6.231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 02/26/2012] [Accepted: 05/27/2012] [Indexed: 02/05/2023] Open
Abstract
The indications for endoscopic treatment have expanded in recent years, and relatively intestinal-type mucosal stomach carcinomas with a low potential for metastasis are now often resected en bloc by endoscopic submucosal dissection (ESD), even if they measure over 20 mm in size. However, ESD requires complex maneuvers, which entails a long operation time, and is often accompanied by complications such as bleeding and perforation. Many technical developments have been implemented to overcome these complications. The scope, cutting device, hemostasis device, and other supportive devices have been improved. However, even with these innovations, ESD remains a potentially complex procedure. One of the major difficulties is poor visualization of the submucosal layer resulting from the poor countertraction afforded during submucosal dissection. Recently, countertraction devices have been developed. In this paper, we introduce countertraction techniques and devices mainly for gastric cancer.
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Affiliation(s)
- Nobuyuki Sakurazawa
- Nobuyuki Sakurazawa, Shunji Kato, Itsuo Fujita, Yoshikazu Kanazawa, Hiroyuki Onodera, Eiji Uchida, Department of Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan
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Nicolás-Pérez D. [Endoscopic submucosal dissection: only for expert endoscopists?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:344-67. [PMID: 22341600 DOI: 10.1016/j.gastrohep.2011.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 12/29/2011] [Indexed: 12/16/2022]
Abstract
Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.
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Affiliation(s)
- David Nicolás-Pérez
- Servicio de Aparato Digestivo, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
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31
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Parra-Blanco A, Nicolas D, Arnau MR, Gimeno-Garcia AZ, Rodrigo L, Quintero E. Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video). Gastrointest Endosc 2011; 74:1137-41. [PMID: 22032320 DOI: 10.1016/j.gie.2011.07.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 07/16/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is the standard of care for treating gastric intramucosal neoplasias in Japan. However, it is seldom performed in Western countries, mainly because it is technically very challenging. Several traction methods have been proposed to facilitate submucosal dissection, but they are usually not widely available or are difficult to apply. OBJECTIVE Our main aim was to evaluate the feasibility of a new method, the clip-band technique, for improving the visualization of the submucosal layer during ESD. DESIGN Observational, experimental, feasibility study conducted in a porcine model. SETTING University Hospital of the Canary Islands, Research Animal Laboratory. PATIENTS Animal study. INTERVENTIONS After completion of the circumferential cutting, a clip-band traction system was applied. MAIN OUTCOME MEASUREMENTS Efficacy and safety of the clip-band technique. RESULTS Eighteen ESDs performed in live domestic pigs were completed without any serious complications. The mean specimen size was 35.38 ± 12.17 mm, the mean cutting time was 13.06 ± 10.52 minutes, and the mean dissection time was 16.67 ± 9.01 minutes. LIMITATIONS The clip-band technique was not compared with the standard ESD technique. CONCLUSIONS This initial study shows that the clip-band traction technique is feasible and that it permits safe, effective, and relatively inexpensive gastric ESD.
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Affiliation(s)
- Adolfo Parra-Blanco
- Endoscopy Unit, Department of Gastroenterology, University Hospital of Canary Islands, Tenerife, Spain.
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