EMR/ESD: Techniques, Complications, and Evidence

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.

Effectiveness of Endoscopic Hemostasis with Soft Coagulation for Non-Variceal Upper Gastrointestinal Bleeding over a 12-Year Period

BACKGROUND/AIMS

In this study, investigations were carried out to ascertain whether soft coagulation hemostasis for non-variceal upper gastrointestinal bleeding (UGIB) has ever been performed in a time-dependent manner.

METHODS

Medical records of 502 patients who had undergone emergency endoscopic hemostasis for non-variceal UGIB from 2003 to 2014 were checked and the modalities were used to achieve hemostasis compared between the first period from 2003 to 2008 (197 patients) and the second period from 2009 to 2014 (305 patients).

RESULTS

Endoscopic hemostasis was successfully achieved in 96.0% of study patients. Peptic ulcers were the main cause of bleeding (89.4%). Endoscopic hemostasis was performed by soft coagulation significantly more frequently during the second (71.1%) than the first period (11.7%; p < 0.001). Endoscopic hemostasis was mainly achieved by trainees during the second period (76.1%); these trainees comprised a significantly greater proportion of endoscopists than during the first period (56.3%; p < 0.001). Endoscopic-related complications did not differ between the 2 periods. The only risk factor for rebleeding after hemostasis was Helicobacter pylori infection; the use of soft coagulation and the fact that endoscopists were just trainees were not risk factors.

CONCLUSION

Our findings suggest that using soft coagulation to achieve endoscopic hemostasis for non-variceal UGIB is safe and effective, even when it is performed by trainees.

Complications related to gastric endoscopic submucosal dissection and their managements

Endoscopic submucosal dissection (ESD) for early gastric cancer is a well-established procedure with the advantage of resection in an en bloc fashion, regardless of the size, shape, coexisting ulcer, and location of the lesion. However, gastric ESD is a more difficult and meticulous technique, and also requires a longer procedure time, than conventional endoscopic mucosal resection. These factors naturally increase the risk of various complications. The two most common complications accompanying gastric ESD are bleeding and perforation. These complications are known to occur both intraoperatively and postoperatively. However, there are other rare but serious complications related to gastric ESD, including aspiration pneumonia, stenosis, venous thromboembolism, and air embolism. Endoscopists should have sufficient knowledge about such complications and be prepared to deal with them appropriately, as successful management of complications is necessary for the successful completion of the entire ESD procedure.

Accuracy of endoscopic ultrasound in preoperative staging of early esophageal cancer: A Meta-analysis

AIM: To evaluate the accuracy of endoscopic ultrasound (EUS) in the preoperative staging of early esophageal cancer.

METHODS: We searched the Medline, PubMed, Web of Science, Embase, Cochrane Central Trials, Wanfang, CBM, CNKI and VIP databases for relevant studies published. Study selection, quality assessment and data extraction were performed by two reviewers independently. Meta-Disc (version1.4) software was used to perform the meta-analysis for sensitivity, specificity, positive likelihood ratio (LR), and negative LR. Pooling results were derived (by) using the fixed-effect model when significant heterogeneity was not present, and the random-effect model was applied otherwise. A summary receiver-operating characteristic (SROC) curve was constructed. Furthermore, to explore the potential sources of heterogeneity, we used meta-regression to estimate the effect of the characteristics of the studies on the diagnostic accuracy of EUS. In addition, the outliers were identified by the method described by Deville and a subgroup analysis was performed by excluding the outliers. We used Stata statistical software (version 10.0) to assess the publication bias using the Begg-Mazumdar indictor and Harbord-Egger indictor.

RESULTS: Twenty studies with a total of 1115 patients were included in this analysis. The pooled sensitivity, specificity, and positive and negative likelihood ratio of EUS for T1m staging were 0.85 (95%CI: 0.83-0.88), 0.86 (95%CI: 0.83-0.89), 5.34 (95%CI: 3.67-7.76), and 0.21 (95%CI: 0.15-0.29), respectively. For stage T1sm, these results were 0.87 (95%CI: 0.84-0.90), 0.85 (95%CI: 0.82-0.88), 4.64 (95%CI: 3.47-6.22), and 0.18 (95%CI: 0.13-0.25). For stage N, these results were 0.71 (95%CI: 0.61-0.80), 0.78 (95%CI: 0.71-0.84), 2.93 (95%CI: 1.49-5.79), and 0.46 (95%CI: 0.18-1.22). The percent of area under the curve was 92.1% for both stage T1m and stage T1sm, and 80% for stage N. No significant publication bias was found with either the Begg-Mazumdar indictor (P = 0.216) or the Harbord-Egger indictor (P = 0. 412).

CONCLUSION: EUS has excellent sensitivity and specificity in diagnosing the T1 stage of early esophageal cancer. However, the frequency of EUS probe and the experience of the endosonographers can affect the diagnostic accuracy of EUS. EUS plays an important role in clinical selection of surgical approaches and treatments.

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.

Advances in treatment of early gastric cancer by endoscopic submucosal dissection

As a result of the emergence and application of magnifying chromoendoscopy, narrow band imaging, confocal laser endoscopy and the enhancement of the awareness of malignant tumors, more and more people have been diagnosed with gastric cancer at early stages. The postoperative five-year survival rate for early gastric cancer (EGC) can reach as high as 90%. Since the emergence of endoscopic submucosal dissection (ESD), its advantage in the treatment of EGC has become more and more evident due to definite therapeutic effect, less physical trauma, high safety, excellent patient compliance, and low therapeutic cost. This paper focuses on the clinical application of ESD in the management of EGC.

Retrospective multicenter study concerning electrocautery forceps with soft coagulation for nonmalignant gastroduodenal ulcer bleeding in Japan

Electrocautery forceps with soft coagulation are actively used for treatment of bleeding and nonbleeding visible vessels during endoscopic submucosal dissection, but the usefulness of gastroduodenal ulcer bleeding has not been elucidated so far. The purpose of this paper is to elucidate the outcomes of electrocautery forceps with soft coagulation for peptic and artificial gastroduodenal ulcer bleeding. A retrospective multicenter study of consecutive case series during one year involved nine departments of high-volume hospitals in Japan. The study included 128 consecutive patients (62 with peptic ulcers and 66 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed using emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out using electrocautery forceps with soft coagulation. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death according to peptic and artificial ulcer bleeding were recorded. Successful initial endoscopic hemostasis was obtained in 61 peptic ulcer patients (98.4%) and 66 artificial ulcer patients (100%). Rebleeding was observed in seven peptic ulcer patients (11.5%) and five artificial ulcer patients (7.6%). Rates of successful management with endoscopic methods alone were 96.8% (60/62) and 100% (66/66) in peptic ulcer patients and artificial ulcer patients, respectively. There were no severe complications or deaths related to the management of gastroduodenal ulcer bleeding. The novel endoscopic method using electrocautery forceps with soft coagulation for gastroduodenal ulcer bleeding seems to provide safety and efficacy that is comparable with that of endoscopic hemostasis with other established hemostatic techniques.

Current managements and outcomes of peptic and artificial ulcer bleeding in Japan

The recent trend of gastroduodenal ulcer bleeding in Japan has not been elucidated in detail and the data for a new categorized type, artificial ulcer bleeding, is completely lacking. The purpose of this paper is to elucidate current managements and outcomes of peptic and artificial ulcer bleeding in Japan. A retrospective multicenter study of consecutive case series was carried out during one year at nine departments of high-volume hospitals in Japan. The study included 325 consecutive patients (239 with peptic ulcers and 86 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed by emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out mainly using endoscopic treatments. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death were recorded according to peptic and artificial ulcer bleeding. Additionally, preferred endoscopic methods, concomitant use of antisecretory drugs, and timing of second-look endoscopy were also measured. A total of 227 (99.1%) of 229 peptic ulcer patients with endoscopic treatment and all (100%) 84 artificial ulcer patients underwent successful tentative hemostasis. Rebleeding occurred in 23 peptic ulcer patients (10.1%) and 10 artificial ulcer patients (11.9%). One peptic ulcer patient and two artificial ulcer patients had final surgical rescue due to rebleeding. No death was observed. Monotherapy was predominant (around 65% of cases) in both types of ulcers. The coagulation forceps method was more frequently applied in artificial ulcers (P < 0.05). A per oral proton pump inhibitor was more frequently used in artificial ulcers (P < 0.05), although an intravenous proton pump inhibitor was used in the majority of patients in both types of ulcers. The frequency of second-look endoscopy in peptic ulcers (88%) was significantly higher than that in artificial ulcers (71%) (P < 0.05). There seemed to be no rule as to the timing of second-look endoscopy, although it was most frequently performed on the day after hemostasis. The recent outcomes of endoscopic treatment for nonmalignant gastroduodenal bleeding in Japan were excellent in both peptic and artificial ulcers with similar efficacies. Although they were minor findings, some differences in applied endoscopic methods, concomitant use of antisecretory drugs, and presence of second-look endoscopy were observed.

Advantages of endoscopic submucosal dissection with needle-knife over endoscopic mucosal resection for small rectal carcinoid tumors: a retrospective study

BACKGROUND

Endoscopic submucosal dissection (ESD) is a new, widely accepted method for the treatment of early gastric cancer and was developed to increase the en bloc resection rate. This study aimed to evaluate the efficacy and safety of ESD compared with conventional endoscopic mucosal resection (EMR) for small rectal carcinoid tumors.

METHODS

A retrospective study was carried out that included 43 patients with small rectal carcinoid tumors (< 10 mm). The cohort comprised two groups: Group A (N = 23) underwent conventional EMR from January 2004 to August 2005, while group B (N = 20) underwent ESD with needle-knife from September 2005 to December 2006. The rate of curative en bloc resection, the procedure time, and the incidence of complications were evaluated.

RESULTS

The en bloc resection rate and the rate of completeness of resection of group B were higher than those of group A (100 vs. 87%, 100 vs. 52.5%, respectively). The average operation time required for resection was significantly longer in group B (28.4 ± 17.2 min) compared with group A (12.3 ± 15.4 min) (p < 0.05). None of the patients had immediate or delayed bleeding during the procedure. Perforation occurred in one case of group B and the patient recovered after several days of conservative treatment. Three patients had local recurrence after EMR, while no patient experienced recurrence after ESD.

CONCLUSION

ESD, compared with conventional EMR, increased en bloc and histologically complete resection rates and may reduce local recurrence rate for small rectal carcinoid tumors. Increased operation time and complication risks with ESD remain problematic. Further technique and investigation are required to confirm the safety and to assess the long-term prognosis of ESD.

Endoscopic submucosal dissection for colorectal neoplasms

Although endoscopic submucosal dissection (ESD) gains acceptance as one of the standard treatments for esophageal and stomach neoplasms in Japan, it is still in the developing stage for colorectal neoplasms. In terms of indications, little likelihood of nodal metastasis and technical resectability are principally considered. Some of intramucosal neoplasms, carcinomas with minute submucosal invasion, and carcinoid tumors, which are technically unresectable by conventional endoscopic treatments, may become good candidates for ESD, considering substantial risks and obtained benefits. ESD as a staging measure to obtain histological information of the invasion depth and lymphovascular infiltration is acceptable because preoperative prediction is difficult in some cases. In terms of techniques, advantages of ESD in comparison with other endoscopic treatments are to be controllable in size and shape, and to be resectable even in large and fibrotic neoplasms. The disadvantages may be longer procedure time, heavier bleeding, and higher possibility of perforation. However, owing to refinement of the techniques, invention of devices, and the learning curve, acceptable technical safety has been achieved. Colorectal ESD is very promising and become one of the standard treatments for colorectal neoplasms in the near future.

Subserosal injection of hyaluronic acid may prevent perforation after endoscopic resection

AIM: To investigate the protective effect of subserosal injection of hyaluronic acid (HA) after endoscopic resection (ER) using ex vivo and in vivo studies.

METHODS: As the first examination, technical application of subserosal injection was tested 10 times using resected porcine stomachs. As the second examination, ER was applied to make six mucosal defects per stomach in three live minipigs and thermal damage was given on the proper muscle layer by using hemostatic forceps. Following the thermocoagulation, 1 mL of normal saline and HA, respectively, was injected targeting the subserosal layer in two mucosal defects each and the rest kept no injection as the control. The minipigs were recovered from the anesthesia and kept fasting until euthanasia which was carried out around 24 h after the procedures.

RESULTS: Ex vivo study revealed that complete and partial subserosal injection was possible two (20%) and four (40%) times, respectively. In vivo study revealed that no postoperative perforation occurred at any point of the thermocoagulation. Apparent retention of hyaluronic acid was identified at only two (33%) points where HA was injected.

CONCLUSION: This study failed to show preventative effects of subserosal injection of HA on postoperative perforation due to technical faults. However, this concept has a possibility to change strategy of ER with further technical innovation.

Endoscopic submucosal dissection for esophageal squamous cell neoplasms

Endoscopic submucosal dissection (ESD) has gradually gained acceptance as one of the standard treatments for early esophageal cancer, as well as for early gastric cancer in Japan, but standardization of the knowledge is still incomplete. The final goal to perform ESD is not to resect the lesion in an en bloc fashion, but to save the patient from esophageal cancer-related death. Thus, the indications should be considered based on the entire patient, not just the target lesion itself, and pre-, peri- and postoperative management of the patient is also very important, as well as technical aspects of ESD. In terms of the techniques of ESD, owing to refinement of the procedural strategy, invention of the devices, and the learning curve, acceptable safety and favorable middle-term efficacy have been obtained. We believe that ESD will become a standard treatment for early esophageal cancer not only in Japan but also worldwide in the near future.

Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases

BACKGROUND & AIMS

The clinical outcomes for endoscopic submucosal dissection (ESD), a novel endoluminal surgery for gastrointestinal neoplasm in the colorectum, are reported.

METHODS

ESD was performed on 186 consecutive patients with 200 colorectal epithelial neoplasms who had preoperative diagnoses of mucosal or slight submucosally invasive neoplasms. In addition, these could be of large size, with submucosal fibrosis, or located on an intestinal fold. The therapeutic efficacy and safety were assessed.

RESULTS

The targeted lesions consisted of 102 adenomas, 72 noninvasive carcinomas, and 26 invasive carcinomas. Seven lesions (3.5%) were histologically considered to be at substantial risk for nodal metastasis after ESD. The rate of en bloc resection was 91.5% (183/200), and en bloc resection with tumor-free lateral/basal margins (R0 resection) was 70.5% (141/200). Two lesions (1%) required emergency colonoscopies as a result of hematochezia after ESD. Eleven (5.5%) immediate perforations that occurred during ESD were successfully managed conservatively, but 1 (0.5%) delayed perforation required laparotomy. Two multiple-piece resections of 111 tumors (1.8%), which were successfully followed by colonoscopy (median follow-up, 18 months; range, 12-60 months), were found as locally recurrent tumors 2 and 21 months after ESD. No lymph node or distant metastasis was detected in 77 patients with noninvasive or invasive carcinoma (median follow-up, 24 months; range, 6-74 months).

CONCLUSIONS

ESD is applicable in the colorectum with promising results. However, when considering the risks and benefits, piecemeal endoscopic resection or colorectal resection might be more appropriate for some subgroups of large flat neoplasms or those with submucosal fibrosis.