Perspective on the practical indications of endoscopic submucosal dissection of gastrointestinal neoplasms

Long-term outcomes after non-curative endoscopic resection for esophageal squamous cell carcinoma followed by additional chemoradiotherapy

Endoscopic resection (ER) of esophageal squamous cell carcinoma (ESCC) is evaluated pathologically, and additional treatment is recommended for cases resulting in non-curative resection, defined as pMM with lymphovascular invasion (LVI), pSM, or positive vertical margin. This study aimed to assess long-term outcomes and risk factors for recurrence in patients with ESCC treated with non-curative ER followed by additional chemoradiotherapy (CRT). We retrospectively reviewed the clinical courses of patients who underwent non-curative ER followed by additional CRT for ESCCs between August 2007 and December 2017. Recurrence rates and risk factors for recurrence were analyzed. Among 97 patients with non-curative ER, 73 underwent additional CRT. With a median follow-up period of 71 months, recurrences were observed in 10 (14%) of 73 patients, with a median interval of 24.5 (1-59 months). The 3- and 5-year recurrence-free survival were 89 and 85%, respectively, and the 3- and 5-year overall survival rates were 96 and 91%, respectively. Multivariate analysis showed that lymphatic invasion was an independent risk factor for recurrence in patients with non-curative ESCC receiving additional CRT. Among the 10 patients with recurrence, 4, 3, 2, and 1 underwent surgery, chemotherapy, supportive care, and CRT, respectively. Notably, all four patients who underwent surgery survived, regardless of regional and/or distant lymph node metastasis. Lymphatic invasion is an independent risk factor for the recurrence of non-curative ESCCs. Careful follow-up is required for at least 5 years after ER with additional CRT.

The Feasibility and Safety of Endoscopic Submucosal Dissection for Circumferential Superficial Esophageal Squamous Cell Neoplasms

Background It remains controversial whether endoscopic submucosal dissection (ESD) is still appropriate for circumferential superficial esophageal squamous cell neoplasms (SESCN), and few studies compared the short-term and long-term outcomes of ESD with radical surgery. Methods A total of 140 patients with SESCN who underwent ESD or surgery between February 2014 and October 2021 were retrospectively reviewed. The characteristics of patients, operative time, postoperative complications, overall survival (OS), recurrence-free survival (RFS), and quality of life (QOL) were compared between the ESD and surgery groups. The effect of different methods to prevent esophageal stenosis after ESD were analysed. Results Drinking, family history of cancer, macroscopic type, and intrapapillary capillary loop (IPCL) type were independent risk factors for deep submucosal invasion (SM ≥ 200 μm). Smoking and IPCL type were independent predictive factors for angiolymphatic invasion. The average operative time of ESD was significantly shorter than that of surgery (174.5 ± 51.16 min vs. 255.9 ± 88.18 min, p < 0.001). The incidence of perioperative complications in ESD group was significantly lower than that in surgery group (5.5% vs. 19.4%, p = 0.015). The ESD group had significantly better functional scale scores for emotional functioning, cognitive functioning, and global health status, and lower rates of pain, dyspnoea, insomnia, appetite loss, diarrhoea, reflux, and trouble with taste than the surgery group. No significant difference in OS and RFS between ESD and surgery group. Conclusions ESD can significantly shorten the operative time and reduce perioperative complications. Additionally, on the premise of using appropriate measures to prevent postoperative stenosis, ESD can be the first choice for the treatment of SESCN, which could provide better QOL, and the long-term prognosis of ESD is no less than that of surgery.

Clinical effectiveness of short course oral prednisone for stricture prevention after semi-circumferential esophageal endoscopic submucosal dissection

Background and study aims  Esophageal strictures (ES) occur frequently after semi-circumferential endoscopic submucosal dissection (ESD) for the eradication of superficial esophageal neoplasms and negatively impact a patient's quality of life. Oral corticosteroids have been shown to be clinically effective, but the most appropriate drug, dose and duration is yet to be determined. The aim of the study was to investigate the clinical effectiveness and safety of 30 mg prednisone with a shortened tapering schedule on ES after semi-circumferential ESD. Patients and methods  This was a retrospective observational study that analyzed consecutive patients with esophageal neoplasms who underwent semi-circumferential ESD with a resection defect greater than 75 % of the circumference that received a protocol of oral steroids for stricture prevention. On postoperative day 3, 30 mg prednisone was prescribed, tapering weekly to 20 mg/10 mg/5 mg over 4 weeks. Follow-up included clinic consultation and endoscopic review at weeks 2 and 4. Effectiveness outcomes included ES rates, safety, tolerability, resection, dilatation and recurrence rates. Results  Ninety ESD procedures were carried out during the specified time period and 18 patients met the inclusion criteria for the final analysis. The mean age was 61.5 years, lesion size was 52.5 mm, and final histology was squamous cell carcinoma in all patients. Incidence of intra-procedure complications was: bleeding 5.5 % (1/18) and ES 5.5 % (1/18), requiring a median two endoscopic dilatations. En bloc, R0 and curative resection rates were 88.8 %, 72.2 %, and 55.5 %, respectively. Conclusions  The short tapering schedule of 30 mg oral prednisone is clinically efficacious and safe for prevention of ES after semi-circumferential ESD in Latin American patients.

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma and current practice is to establish endoscopic surveillance once diagnosed, in order to identify early dysplasia and neoplasia that has the potential to undergo endoscopic eradication therapy (EET). Before embarking upon EET the clinical team has a duty to consider all viable options and come to a plan based on recent evidence. The therapeutic approach varies greatly but largely adheres to the mantra of 'Detect-Resect-Ablate', in which high-quality endoscopy identifies BE associated pathology, associated lesions (if present) undergo safe endoscopic resection and remaining intestinal metaplasia in the esophagus is ablated to prevent recurrence of dysplasia. In this review, current practice, pitfalls, complications, and the future perspectives on practice in this field are discussed. The Western perspective is focused on here, with an outline of the differences in clinical practice with Asian nations and attempts to bridge these differences.

Quercetin as an anticancer agent: Focus on esophageal cancer

Esophageal cancer (EC) is regarded as the sixth highest contributor to all cancer-related mortality, worldwide. In spite of advances in the treatment of EC, currently used methods remain ineffective. Quercetin, as a dietary antioxidant, is a plant flavonol from the flavonoid group of polyphenols, and can be found in numerous vegetables, fruits, and herbs. Quercetin can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential apoptosis effects, and antioxidant properties. Of the various types of cancer, the use of quercetin has now become prominent in the treatment of EC. In this review, we discuss how quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin, and low-cost relative to synthetic cancer drugs. However, most findings cited in the current study are based on in vitro and in vivo studies, and thus, further human-based research is necessitated. PRACTICAL APPLICATIONS: In spite of advances in the treatment of esophageal cancer, currently used methods remain ineffective, therefore, an alternative or complementary therapy is required. Quercetin, as a dietary antioxidant, can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential proapoptotic functions, and antioxidant properties. Quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin. The low cost of quercetin as supplement or dietary intake, relative to synthetic cancer drugs, is an advantage of the compound which should be considered.

Risk factors of electrocoagulation syndrome after esophageal endoscopic submucosal dissection

AIM

To investigate post endoscopic submucosal dissection electrocoagulation syndrome (PEECS) of the esophagus.

METHODS

We analyzed 55 consecutive cases with esophageal endoscopic submucosal dissection for superficial esophageal squamous neoplasms at a tertiary referral hospital in South Korea. Esophageal PEECS was defined as "mild" meeting one of the following criteria without any obvious perforation: fever (≥ 37.8 °C), leukocytosis (> 10800 cells/μL), or regional chest pain more than 5/10 points as rated on a numeric pain intensity scale. The grade of PEECS was determined as "severe" when meet two or more of above criteria.

RESULTS

We included 51 cases without obvious complications in the analysis. The incidence of mild and severe esophageal PEECS was 47.1% and 17.6%, respectively. Risk factor analysis revealed that resected area, procedure time, and muscle layer exposure were significantly associated with PEECS. In multivariate analysis, a resected area larger than 6.0 cm2 (OR = 4.995, 95%CI: 1.110-22.489, P = 0.036) and muscle layer exposure (OR = 5.661, 95%CI: 1.422-22.534, P = 0.014) were independent predictors of esophageal PEECS. All patients with PEECS had favorable outcomes with conservative management approaches, such as intravenous hydration or antibiotics.

CONCLUSION

Clinicians should consider the possibility of esophageal PEECS when the resected area exceeds 6.0 cm2 or when the muscle layer exposure is noted.

Polish Consensus on Treatment of Gastric Cancer; update 2017

The "Polish Research on Gastric Cancer" project has been continued since 1986. The main aim of this project, which is a multicenter and interdisciplinary research, is enhancing the treatment results of gastric cancer patients by developing and promoting the use of optimal methods for diagnosis and treatment, both surgical as well as combined. One of the more important achievements of the project is the development and publication of a document named "Polish Consensus on Treatment of Patients with Gastric Cancer", whose first version was published in 1998. Following versions were updated adequately to changing trends in the proceedings in patients with gastric cancer. A scientific symposium on "Polish Consensus on Treatment of Gastric Cancer - update 2016" was held in 3-4 June 2016 in Cracow. During the symposium a panel session was held during which all authors publicly presented the Consensus assumptions to be discussed further. Moreover, the already mentioned session was preceded by a correspondence as well as a working meeting in order to consolidate the position. It has to be underlined that the directions and guidelines included in the Consensus are not the arbitrarily assumed rules of conduct in a legal aspect and as such every doctor/team of doctors is entitled to make different decisions as long as they are beneficial to a patient with gastric cancer. The Consensus discusses as follows: a) recommended qualifications (stage of advancement, pathological, lymph node topography and the extent of lymphadenectomy, division of cancer of the gastroesophageal junction), b) rules for diagnostics including recommendations regarding endoscopic examination and clinical evaluation of the advancement stage, c) recommendations regarding surgical treatment (extent of resection, extent of lymphadenectomy, tactics of proceedings in cancer of the gastroesophageal junction), d) recommendations regarding combined treatment with chemotherapy or radiotherapy, e) place of endoscopic and less invasive surgery in the treatment of gastric cancer. This publication is a summary of the arrangements made in the panel session during the abovementioned scientific symposium in Cracow in 2016.

Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States

BACKGROUND AND AIMS

The role of endoscopic submucosal dissection (ESD) in Barrett's early neoplasia is not well defined, with most studies originating from Asia and Europe. We aimed to assess the efficacy, safety, and results of ESD in Barrett's esophagus (BE) with high-grade dysplasia (HGD) and early adenocarcinoma (EAC) across centers in the United States.

METHODS

Multicenter retrospective analysis on 46 patients with BE who underwent ESD for BE-HGD or EAC, or both, between January 2010 and April 2015. The primary endpoint was the rate of en bloc resection. Secondary aims included rate of R0 (complete) and curative resection, a comparison of pre- and post-ESD histology, procedure-related adverse events, and rate of remission at follow-up.

RESULTS

Median age was 69 years (range, 42-82 years). The median resected specimen size was 45 mm (range, 13-125 mm). En bloc and curative resection rates were 96% (44/46) and 70% (32/46), respectively. Most lesions (11/20; 55%) diagnosed as BE-HGD on biopsy were upstaged to intramucosal or invasive EAC on post-ESD histopathology. There were 4 early (<48 hours) adverse events (3 bleeding and 1 perforation), and all were treated endoscopically. Seven patients (15%) developed esophageal strictures that were managed endoscopically. Complete remission of BE neoplasia was found in 100% (32/32) of patients with curative resection at median follow-up of 11 months (range, 2-25 months).

CONCLUSIONS

This is the largest multicenter series of ESD for early neoplastic BE from the United States. ESD appears to be safe and effective, with high en bloc and curative resection rates in the treatment of early BE neoplasia.

Efficacy of prednisone for prevention of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

BACKGROUND

Our objective was to investigate the efficacy and safety of oral prednisone for the prevention of esophageal stricture formation after endoscopic submucosal dissection (ESD) in an optimal administration program.

METHODS

Patients who underwent circumferential or semi-circumferential (more than three quarters but not a complete circular) ESD for esophageal squamous cell carcinoma were eligible for this study. Oral prednisolone was administered to the study group at a dose of 30 mg/day on the third day post-ESD, and then tapered gradually (30, 25, 20, 15, 10, and 5 mg for 14 days). Serial esophagoscopy with iodine staining was performed to assess stenosis and tumor recurrence at one, three, six, and 12 months after ESD. Endoscopic balloon dilatation was performed whenever patients experienced persistent dysphagia to solids. Data were statistically analyzed.

RESULTS

Twenty-three patients (15 men, mean age 66.6 years) were enrolled in the study. Post-procedural esophageal stricture was significantly lower in the study group (23.1%) compared to the control (80%) (P < 0.05). A significantly higher number of endoscopic balloon dilatation sessions were performed (P < 0.05) in the control (13.5) than in the study group (0.69). There were no adverse events related to oral prednisolone or the procedure itself and no treatment-related mortality was observed during the 12 month follow-up.

CONCLUSIONS

Our study suggested an optimal administration program of oral prednisone therapy and demonstrated that it is safe and effective for the prevention of esophageal stricture in patients after complete or semi-circular ESD for esophageal squamous cell carcinoma.

Combined Endoscopic Laparoscopic Surgery Procedures for Colorectal Surgery

Colonoscopy is the standard of care for screening and surveillance of colorectal cancers. Removal of adenomatous polyps prevents the transformation of adenomas to potential adenocarcinoma. While most polyps are amenable to simple endoscopic polypectomy, difficult polyps that are large, broad-based, or located in haustral folds or in tortuous colon segments can present a challenge for endoscopists. Traditionally, patients with endoscopically unresectable polyps have been referred for oncologic surgical resection due to the underlying risk of malignancy within the polyp; however, the majority of these polyps are benign on final pathology. Combined endoscopic laparoscopic surgery can help facilitate endoscopic removal of difficult lesions, or allow the surgeon to select the correct laparoscopic approach for polyp excision. Current literature suggests that these procedures are safe and effective and can potentially save patients from the morbidity of laparotomy and segmental colectomy.

Current Status and Future Prospects for Esophageal Cancer Treatment

The local control effect of esophagectomy with three-field lymph node dissection (3FLD) is reaching its limit pending technical advancement. Minimally invasive esophagectomy (MIE) by thoracotomy is slowly gaining acceptance due to advantages in short-term outcomes. Although the evidence is slowly increasing, MIE is still controversial. Also, the results of treatment by surgery alone are limiting, and multimodality therapy, which includes surgical and non-surgical treatment options including chemotherapy, radiotherapy, and endoscopic treatment, has become the mainstream therapy. Esophagectomy after neoadjuvant chemotherapy (NAC) is the standard treatment for clinical stages II/III (except for T4) esophageal cancer, whereas chemoradiotherapy (CRT) is regarded as the standard treatment for patients who wish to preserve their esophagus, those who refuse surgery, and those with inoperable disease. CRT is also usually selected for clinical stage IV esophageal cancer. On the other hand, with the spread of CRT, salvage esophagectomy has traditionally been recognized as a feasible option; however, many clinicians oppose the use of surgery due to the associated unfavorable morbidity and mortality profile. In the future, the improvement of each treatment result and the establishment of individual strategies are important although esophageal cancer has many treatment options.

Prevention of Esophageal Strictures After Endoscopic Submucosal Dissection: A Promising Therapy Using Carboxymethyl Cellulose Sheets

BACKGROUND

Esophageal stricture is one of the serious adverse events following endoscopic submucosal dissection (ESD). However, optimum preventive techniques are still lacking.

AIMS

Our primary objective was to evaluate the incidence of post-ESD esophageal stricture with the application of carboxymethyl cellulose (CMC) sheets. Secondary objectives were to determine the number of sessions of endoscopic balloon dilatation (EBD) required to resolve post-ESD strictures and the incidence rate of peri-operative adverse events.

METHODS

This was a pilot, single-center, prospective study. Seven patients who had high risks of developing post-ESD esophageal stricture were enrolled into our study. CMC sheets were applied to the mucosal defects immediately after the completion of ESD. Patients were monitored and reviewed after ESD to detect any adverse events.

RESULTS

The incidence rate of post-operative stricture was 57 % (4/7 patients). Among patients who required EBD, the number of sessions performed was 2.8 ± 2.2. No serious post-operative adverse events were reported.

CONCLUSION

The use of CMC sheets appears to be a safe and effective prophylactic treatment for esophageal stricture following extensive ESD.

Usefulness of endoscopic resection using the band ligation method for rectal neuroendocrine tumors

Background/Aims

Rectal neuroendocrine tumors (NETs) are among the most common of gastrointestinal NETs. Due to recent advances in endoscopy, various methods of complete endoscopic resection have been introduced for small (≤10 mm) rectal NETs. However, there is a debate about the optimal treatment for rectal NETs. In our study, we aimed to evaluate the efficacy and feasibility of endoscopic resection using pneumoband and elastic band (ER-BL) for rectal NETs smaller than 10 mm in diameter.

Methods

A total of 55 patients who were diagnosed with rectal NET from January 2004 to December 2011 at Gil Medical Center were analyzed retrospectively. Sixteen patients underwent ER-BL. For comparison, 39 patients underwent conventional endoscopic mucosal resection (EMR).

Results

There was a markedly lower deep margin positive rate for ER-BL than for conventional EMR (6% [1/16] vs. 46% [18/39], P=0.029). Four patients who underwent conventional EMR experienced perforation or bleeding. However, they recovered within a few days. On the other hand, patients whounderwent endoscopic resection using a pneumoband did not experience any complications. In multivariate analysis, ER-BL (P=0.021) was independently associated with complete resection.

Conclusions

ER-BL is an effective endoscopic treatment with regards to deep margin resection for rectal NET smaller than 10 mm.

Clinical Outcomes of Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Neoplasms

Background/Aims:

Endoscopic treatment has been broadly applied to superficial esophageal neoplasms. Endoscopic submucosal dissection (ESD) allows for high rates of en bloc resection, precise histological assessment, and low rates of local recurrence. The aim of this study was to evaluate the outcomes of ESD for superficial esophageal neoplasms.

Methods:

We retrospectively reviewed 36 esophageal ESDs for superficial squamous neoplasms in 32 patients between March 2009 and August 2014 at Gangnam Severance Hospital.

Results:

The median patient age was 64 years, and 30 men were included. The indications were early squamous cell carcinoma in 26 lesions, adenoma with high-grade dysplasia in five lesions, and low-grade dysplasia in five lesions. The en bloc resection and R0 resection rates were 97.2% (35 of 36) and 91.7% (33 of 36), respectively. Microperforation and post-ESD bleeding occurred in 5.6% (2 of 36) and 5.6% (2 of 36), respectively. Post-ESD esophageal strictures developed in five patients (13.9%). Five patients (15.6%) had an additional treatment after ESD (concurrent chemoradiation therapy in three, radiation therapy in one, and surgery in one patient). There was no disease-specific mortality during the median follow-up of 31 months.

Conclusions:

Favorable clinical outcomes were observed in ESD for superficial esophageal squamous neoplasms. Esophageal ESD could be a good treatment option in terms of efficacy and safety.

Nonsurgical treatment of 8 cases with esophageal perforations caused by ESD

BACKGROUND

Esophageal perforation is a serious, but rare complication of high mortality following the endoscopic submucosal dissection (ESD) procedure. The aim of this study is to evaluate the efficacy and safety of nonsurgical treatment of esophageal perforations caused by ESD based on our clinical experience.

METHODS

From January 2009 to November 2013, 8 patients were diagnosed with endoscopic perforation of the esophagus caused by ESD in our center. All cases were treated with nonsurgical measures, such as metallic clips, conservative treatment alone and therapeutic drainage.

RESULTS

The places of perforation were closured by metallic clips immediately in 4 patients. Two patients were cured with conservative treatment alone. Therapeutic drainage with large-bore tube thoracostomy was applied in another 2 patients who had empyema following esophageal perforation. All of the patients were treated nonsurgically, and recovered well.

CONCLUSION

Esophageal perforation caused by ESD can be detected and treated timely, and nonsurgical treatment seems to be a feasible and effective option for clinicians.

Application of carbon nanoparticles to mark locations for re-inspection after colonic polypectomy

BACKGROUND

Endoscopic surgery has been a novel treatment for colon polyps or even early colorectal cancer. However, the exact re-inspection after colonic polypectomy to detect the scar from polyp removal was difficult to be performed. In our previous study, colon cancer tattooed with carbon nanoparticles was easily found during surgery. We speculated that carbon nanoparticles could be used in exact re-inspection after colonic polypectomy.

OBJECTIVE

To evaluate the efficiency of carbon nanoparticles for re-inspection after colonic polypectomy.

METHODS

Twenty-four patients with precancerous lesion or early colorectal cancer that underwent colonoscopic polypectomy between October 2012 and December 2013 were enrolled in the study. Participants were divided into two groups. Group A patients were injected with carbon nanoparticles beneath the lesion sites 3 cm. Group B patients were not treated with nanoparticles. All patients underwent quarterly colonoscopies. Once the colonoscope was withdrawn from the site last time record, the time spent searching for lesions was recorded.

RESULTS

There were no significant differences between general conditions or lesion pathology between the groups. The time spent searching for lesions in Group B was much longer than that in Group A (13.67 ± 8.07 vs. 1.21 ± 0.39 min, P < 0.001). Carbon nanoparticles marked lesions for 12 months in some patients, and no adverse reactions were reported.

LIMITATIONS

It was a small sample study.

CONCLUSIONS

Tattooing lesions using carbon nanoparticles suspensions is safe. The durability of dye enables lesions to be re-checked by colonoscopy or laparoscopy for up to 1 year.

Preoperative classification of submucosal fibrosis in colorectal laterally spreading tumors by endoscopic ultrasonography

BACKGROUND AND STUDY AIMS

Although endoscopic submucosal dissection (ESD) is an established therapy for colon neoplasms including laterally spreading tumors (LSTs), its application to advanced fibrotic lesions is very difficult owing to the thin walls of the large intestine. We examined the ability of preoperative endoscopic ultrasonography (EUS) to predict lesion fibrosis in patients undergoing colorectal ESD.

PATIENTS AND METHODS

From 2009 to 2013, 58 LSTs were evaluated retrospectively with EUS and treated using colorectal ESD. The degree of submucosal fibrosis was determined during ESD and classified as F0 (no fibrosis), F1 (mild fibrosis), or F2 (severe fibrosis).

RESULTS

The sensitivity and specificity of fibrosis prediction by preoperative EUS of all cases were 77.8 % and 57.1 %, respectively. However, there was a high accuracy (97.2 %, 35/36) for only the 36 LSTs with clear and visible images. In one case, EUS diagnosed no fibrosis but significant fibrosis was found during ESD, the result of colon cancer invasion into the submucosa.

CONCLUSIONS

Preoperative EUS before colorectal ESD successfully predicted the degree of fibrosis in a number of cases.

Efficacy of short period, low dose oral prednisolone for the prevention of stricture after circumferential endoscopic submucosal dissection (ESD) for esophageal cancer

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) was developed in Japan and has been performed on many patients with early stage esophageal cancer; however quality of life in patients with postoperative stricture is drastically decreased and repeat, periodic endoscopic balloon dilatation (EBD) is usually required over long periods. In this study, we evaluate the efficacy of short period, low dose oral prednisolone in controlling post-procedural esophageal stricture.

PATIENTS AND METHODS

In total, 33 patients who underwent semicircular or complete circular ESD for esophageal superficial squamous cell carcinoma were included in this study. They were divided into two groups: those who underwent large-circumference ESD with no preventative treatment for stricture (ESD alone group) and those who received systemic steroid treatment for stricture (oral prednisolone group). We compared the two groups in terms of stricture rate and total number of EBD sessions. The ESD alone group underwent no preventative treatment. The oral prednisolone group started with 30 mg/day prednisolone on the second day post-ESD, and continued with a gradually tapering prednisolone dose, finally discontinuing systemic steroid administration 3 weeks later.

RESULTS

The stricture rate after ESD was significantly lower in the oral prednisolone group (3 of 17 patients; 17.6 %) than in the ESD alone group (11 of 16 patients; 68.7 %) (P < 0.01). The number of EBD sessions was significantly lower in the oral prednisolone group than in the ESD alone group (median 4.6, range 2 - 10 vs. median 8.1, range 1 - 18; P < 0.01).

CONCLUSION

Short period, low dose oral prednisolone showed promising results for the prevention of stricture after ESD for early stage esophageal cancers.

East Meets West-A Novel Steerable Grasper to Facilitate Gastric Endoscopic Submucosal Dissection (ESD): Randomized Comparative Study in a Porcine Model

BACKGROUND

Endoscopic submucosal dissection (ESD) is challenging because of the limited ability of conventional endoscopic tools to achieve adequate traction. We have recently used a novel steerable grasper (SG; ANUBIS grasper, Karl Storz, Tüttlingen, Germany) with intuitive manipulating handles to lift up the mucosa. The aim of this study is to evaluate the efficacy of the assistance of the SG in a porcine acute model.

MATERIALS AND METHODS

A total of 36 gastric ESDs were performed in 12 swine (3 ESDs/pig), at the antrum, greater curvature of the gastric body, and cardia. Pigs were randomly assigned to the SG group (n = 6) or to the control group (n = 6). ESD steps included the following: scoring the area, submucosal injection, and precut and submucosal dissection with or without SG assistance. Outcomes measured were as follows: dissection time, dissection speed, size of specimen, completeness of dissection (all marks included in the specimen), en bloc dissection, and complications.

RESULTS

Overall mean dissection time was 18.6 ± 7.56 versus 29 ± 18.14 minutes (P = .032), and mean dissection speed was 94.74 ± 39.74 mm(2)/min versus 65.41 ± 39.5 mm(2)/min (P = .033) in the SG and control groups, respectively. Mean size of the specimen was 1451.4 ± 549.2 mm(2) in the SG group and 1615.3 ± 605.9 in the control group. Complete and en bloc dissections were achieved in all cases. One deep muscular injury occurred in the control group (gastric body).

CONCLUSION

The ANUBIS grasper is a user-friendly, effective, and safe tool to achieve adequate traction and exposure of the ESD plane in the pig model.

Disseminated nocardiosis during systemic steroid therapy for the prevention of esophageal stricture after endoscopic submucosal dissection

An 85-year-old man underwent endoscopic submucosal dissection for a large superficial esophageal epithelial neoplasm, which required removal of 95% of the circumference of the esophageal mucosa. Steroids were given orally to prevent esophageal stricture starting on day 3 postoperatively. In the 6th week of steroid treatment, he developed high fever without other symptoms. Chest computed tomography revealed a nodular lesion in the lung. Sputum sample showed Gram-positive, branching, filamentous bacteria, and a diagnosis of nocardiosis was suspected. Brain magnetic resonance imaging revealed multiple focal lesions which indicated dissemination of nocardiosis. Trimethoprim-sulfamethoxazole was immediately started, which led to the disappearance of pulmonary and cerebral nocardiosis with alleviation of fever. Recently, oral steroid treatment has been widely used for the prevention of esophageal stricture. However, the present case indicates the risk of life-threatening infection and the importance of close monitoring of this treatment.

Untutored learning curve to establish endoscopic submucosal dissection on competence level

BACKGROUNDS/AIMS

Endoscopic submucosal dissection (ESD) of early cancer allows precise staging and avoids recurrence or surgery. Tutored by experts, ESD has rapidly spread in Japan, but still demands untutored learning in Western countries. A step-up approach starts with easiest gastric neoplasias, but fails on their low prevalence in Western countries. A prevalence-based approach includes challenging colonic neoplasias.

METHODS

We analyzed an untutored series of initial 50 ESD procedures by an experienced endoscopist on consecutive lesions referred according to prevalence.

RESULTS

Overall, 48 lesions (20% upper gastrointestinal, 80% colorectal; 2 hyperplastic (inflammatory) lesions, 46 neoplasms) were completely resected intention-to-treat with ESD, 2 required a second ESD. Neoplasias were resected 76% en-bloc (46% ESD, 30% ESD with snaring), 17% by ESD with snaring in 2-3 pieces, and 6.5% as ESD with snaring in multiple pieces. None of 15 neoplasias with high-grade intraepithelial neoplasia or an early esophageal cancer (R0) had recurred. Complications were 2 bleedings (4%) and 7 perforations (14%), 5 clipped and 2 (4%) operated. All patients were discharged within 9 days without long-term morbidity.

CONCLUSION

Untutored learning of ESD is feasible on colonic lesions. We propose to establish ESD in Europe with structured training and a prevalence-of-lesions-based approach.

Stricture occurring after endoscopic submucosal dissection for esophageal and gastric tumors

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric and esophageal cancer. Compared to endoscopic mucosal resection, ESD has the advantage of enabling en bloc removal of tumors regardless of their size. However, ESD can result in a large artificial ulcer, which may lead to a considerable deformity. Circumferential mucosal defects of more than three-fourths the esophageal circumference, long longitudinal mucosal defects (>30 mm), and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus. In the stomach, a circumferential mucosal defects more than three-fourths in extent and longitudinal mucosal defects >5 cm are risk factors of post-ESD stricture. If scheduled early, regular endoscopic balloon dilation is effective in controlling and preventing post-ESD stricture. Moreover, intralesional steroid injections or oral steroids can achieve remission of dysphagia or reduce the need for repeated endoscopic balloon dilation. However, further study is needed to improve the prevention of stricture formation.

Esophageal Cancer: Current Options for Therapeutic Management

BACKGROUND

Esophageal cancer (EC) is the eighth most common cancer worldwide. A worldwide-established consensus on therapeutic pathways for EC is still missing. Debate exists on whether neoadjuvant and adjuvant treatment regimens improve the prognosis and which surgical approach reaches objective benefits.

SUMMARY

This article discusses the appropriate option of the current different curative treatments in patients with EC, including surgical treatment and adjuvant therapy.

KEY MESSAGE

To maximize survival and quality of life and also decrease postoperative complications, the present recommended therapeutic management of EC should be individualized multidisciplinary team approaches according to patients' staging and physiologic reserve.

PRACTICAL IMPLICATIONS

The aim of this article is to provide a decision support and also a discussion based on clinical therapeutic strategy in order to characterize the beneficial approach which reaches an optimal balance between radical resection, postoperative outcome and long-term survival of EC.

Endoscopic submucosal dissection for upper gastrointestinal lesions: Our experience with 50 cases

AIM: To discuss the clinical value of endoscopic submucosal dissection (ESD) for treating upper gastrointestinal lesions.

METHODS: A total of 52 patients who underwent ESD between May 2012 and May 2013 were retrospectively analyzed to assess the feasibility, safety and efficacy of ESD for treating upper gastrointestinal lesions.

RESULTS: Among 52 patients, 4 had esophageal lesions, 48 had gastric lesions. Postoperative pathology revealed that 40 were mucosal lesions, including esophageal papilloma (n = 2), cardiac hyperplastic polyps (n = 9), cardiac adenoma (n = 3), early gastric cancer (n = 2), high grade intraepithelial neoplasia (n = 3), low grade intraepithelial neoplasia (n = 5), gastric antral adenomatous polyps (n = 9), hyperplastic polyps (n = 5), and intestinal metaplasia (n = 2); and 12 were submucosal lesions, including esophageal leiomyoma (n = 1), esophageal gastrointestinal stromal tumor (n = 1), gastric heterotopic pancreas (n = 7), gastric body gastrointestinal stromal tumor (n = 2), and lipoma (n = 1). All the lesions were completely resected and were confirmed by pathologic examination. No severe bleeding occurred. Perforation occurred in two cases but was safely managed by conservative treatment.

CONCLUSION: ESD is a safe, effective and recommendable treatment for upper gastrointestinal lesions. It can not only resect the lesions completely, but also provide accurate pathologic information.

Characteristics of gastrointestinal symptoms and function following endoscopic submucosal dissection and treatment of the gastrointestinal symptoms using rikkunshito

The aim of the present study was to investigate the gastrointestinal (GI) symptoms and gastric emptying following endoscopic submucosal dissection (ESD), as well as to evaluate a novel treatment strategy using rikkunshito, a traditional Japanese herbal medicine. GI symptoms and gastric emptying were evaluated 6–8 days after ESD as part of the Step I study. In the Step 1 study, the Gastrointestinal Symptom Rating Scale (GSRS) scores of the two groups after 4 and 8 weeks of treatment with either a proton pump inhibitor (PPI; PPI monotreatment group, n=5) or a PPI plus rikkunshito (PPI + rikkunshito group, n=8) were compared against baseline values. Abdominal pain and constipation occurred in the majority of patients after ESD. The mean T-max 6–8 days after gastric emptying was 75.4±13.6 min, which was significantly longer compared with that reported in healthy subjects (43.9±10.3 min). In the Step 2 study, the total GSRS score was significantly improved only in the PPI + rikkunshito group after 8 weeks of treatment. In conclusion, ESD affects gastric emptying and is associated with an increased incidence of upper GI symptoms such as abdominal pain and indigestion. Rikkunshito may be useful as a novel supporting therapeutic drug for the treatment of GI symptoms in patients who have undergone ESD.

Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy

In the present review the authors discuss the standard ways of preoperative work-up for a suspected large rectal non-invasive lesion, comparing East and West different attitudes both in staging and treatment. Looking at the literature and analyzing recent personal data, neither pit-pattern classification, nor EUS, nor biopsy histology, nor lifting sign verification, nor digital examination allow a specificity of more than three fourth of such cases. The authors disquisition about which optimal treatment excludes a role for EMR for the impossibility to obtain a single en-bloc specimen, minimum requirement for a correct lateral and vertical margin assessment. For the same reason ESD should be preferred, although a recent meta-analysis of the literature defined that one fourth of patients undergoing ESD for a preoperatively assessed non-invasive large rectal lesion fail to receive an R0 en-bloc resection. This forces about 10% of patients treated by flexible endoscopy to undergo abdominal surgery, which is about fourfold higher than TEM. While awaiting further implementation of modern technologies both to improve staging and to reduce invasiveness, a full-thickness excision of the rectal wall by TEM still represents the standard treatment even for suspected benign diseases.

Assessment of vascular invasion in gastric cancer: A comparative study

AIM: To evaluate and compare detection of lymphatic and blood vessel invasion (LVI and BVI) by hematoxylin-eosin (HE) and immunohistochemistry (IHC) in gastric cancer specimens, and to correlate with lymph node status.

METHODS: IHC using D2-40 (a lymphatic endothelial marker) and CD34 (a pan-endothelial marker) was performed to study LVI and BVI in surgical specimens from a consecutive series of 95 primary gastric cancer cases. The results of the IHC study were compared with the detection by HE using McNemar test and kappa index. The morphologic features of the tumors and the presence of LVI and BVI were related to the presence of lymph node metastasis. A χ² test was performed to obtain associations between LVI and BVI and other prognostic factors for gastric cancer.

RESULTS: The detection rate of LVI was considerably higher than that of BVI. The IHC study identified eight false-positive cases and 13 false-negative cases for LVI, and 24 false-positive cases and 10 false-negative cases for BVI. The average Kappa value determined was moderate for LVI (κ = 0.50) and low for BVI (κ = 0.20). Both LVI and BVI were statistically associated with the presence of lymph node metastasis (HE: P = 0.001, P = 0.013, and IHC: P = 0.001, P = 0.019). The morphologic features associated with LVI were location of the tumor in the distal third of the stomach (P = 0.039), Borrmann’s macroscopic type (P = 0.001), organ invasion (P = 0.03) and the depth of tumor invasion (P = 0.001). The presence of BVI was related only to the depth of tumor invasion (P = 0.003).

CONCLUSION: The immunohistochemical identification of lymphatic and blood vessels is useful for increasing the accuracy of the diagnosis of vessel invasion and for predicting lymph node metastasis.

Endoluminal surgical triangulation: overcoming challenges of colonic endoscopic submucosal dissections using a novel flexible endoscopic surgical platform: feasibility study in a porcine model

BACKGROUND

Colonic endoscopic submucosal dissection (ESD) is challenging as a result of the limited ability of conventional endoscopic instruments to achieve traction and exposure. The aim of this study was to evaluate the feasibility of colonic ESD in a porcine model using a novel endoscopic surgical platform, the Anubiscope (Karl Storz, Tüttlingen, Germany), equipped with two working channels for surgical instruments with four degrees of freedom offering surgical triangulation.

METHODS

Nine ESDs were performed by a surgeon without any ESD experience in three swine, at 25, 15, and 10 cm above the anal verge with the Anubiscope. Sixteen ESDs were performed by an experienced endoscopist in five swine using conventional endoscopic instruments. Major ESD steps included the following for both groups: scoring the area, submucosal injection of glycerol, precut, and submucosal dissection. Outcomes measured were as follows: dissection time and speed, specimen size, en bloc dissection, and complications.

RESULTS

No perforations occurred in the Anubis group, while there were eight perforations (50 %) in the conventional group (p = 0.02). Complete and en bloc dissections were achieved in all cases in the Anubis group. Mean dissection time for completed cases was statistically significantly shorter in the Anubis group (32.3 ± 16.1 vs. 55.87 ± 7.66 min; p = 0.0019). Mean specimen size was higher in the conventional group (1321 ± 230 vs. 927.77 ± 229.96 mm(2); p = 0.003), but mean dissection speed was similar (35.95 ± 18.93 vs. 23.98 ± 5.02 mm(2)/min in the Anubis and conventional groups, respectively; p = 0.1).

CONCLUSIONS

Colonic ESDs were feasible in pig models with the Anubiscope. This surgical endoscopic platform is promising for endoluminal surgical procedures such as ESD, as it is user-friendly, effective, and safe.

The accuracy of probe-based confocal endomicroscopy versus conventional endoscopic biopsies for the diagnosis of superficial gastric neoplasia (with videos)

BACKGROUND

Probe-based confocal laser endomicroscopy (pCLE) allows real-time in vivo histologic evaluation of GI mucosal lesions. Although pCLE has been used for various GI disorders, the significance of pCLE for gastric lesions is largely unknown.

OBJECTIVE

We compared the accuracy of conventional endoscopic forceps biopsy and pCLE for the diagnosis of superficial gastric neoplasia before endoscopic resection.

DESIGN

Prospective comparative study.

SETTING

Single tertiary referral center.

PATIENTS

This study involved 54 superficial gastric neoplasias in 46 patients.

MAIN OUTCOME MEASUREMENT

Accuracy of in vivo and offline pCLE diagnosis and interobserver agreement.

METHODS

pCLE was performed before endoscopic resection of superficial gastric neoplasias previously diagnosed by endoscopic biopsy. The overall accuracy of endoscopic, in vivo pCLE, and offline pCLE diagnosis was compared with postendoscopic resection histopathology.

RESULTS

Endoscopic resection was performed on 54 lesions. On final histopathology, there were 3 non-neoplastic lesions, 19 gastric dysplasias, 22 differentiated adenocarcinomas, and 10 undifferentiated adenocarcinomas. The overall agreement with the final histopathology was substantial for conventional biopsies (κ = 0.617) and excellent for in vivo pCLE (κ = 0.824) (P < .001). The overall accuracy for the diagnosis of adenocarcinoma was 91.7% for pCLE and 85.2% for conventional biopsies (P = .065). The combined accuracy of conventional endoscopic biopsies and pCLE was 98.1%. The interobserver agreement for offline pCLE diagnosis was excellent (κ = 0.931).

LIMITATIONS

Single-center study, small sample size.

CONCLUSION

Our study showed that pCLE can provide an accurate diagnosis for superficial gastric neoplasia. pCLE has the potential to compensate for the inherent limitations of a conventional endoscopic biopsy.

Management of complications associated with endoscopic submucosal dissection/ endoscopic mucosal resection for esophageal cancer

Endoscopic resection of early esophageal cancer (EEC) is an established therapy in Japan and is increasingly becoming accepted and used regularly in other countries. Endoscopic submucosal dissection (ESD), an application of conventional endoscopic mucosal resection (EMR), has been developed to allow the resection of larger lesions in an en bloc manner; the earliest results so far have been promising even in EEC. ESD allows precise assessment of the histopathological curability of resected specimens, reducing local recurrence. However, ESD has relatively high complication rates; notification of perforation risk is essential especially in the esophagus. Bleeding during ESD can be managed by endoscopic closure with endoclips, and delayed bleeding is rare. Esophageal stricture following semicircular or complete circular esophageal ESD was relatively frequent even when treated by multiple pre-emptive endoscopic balloon dilation. Endoscopic triamcinolone injection, temporal stenting and innovative transplantation of autologous tissue-engineered epithelial cell sheets have shown promising results for the prevention of luminal stricture following semicircular esophageal ESD. In cases of circumferential ESD, however, giving oral prednisolone can offer a unique treatment option for the prevention of intractable post-procedural stricture of the esophagus.

Pathological evaluation of gastrointestinal endoscopic submucosal dissection materials based on Japanese guidelines

Endoscopic surgery first started as snare polypectomy and then progressed to endoscopic mucosal resection (EMR). In order to resect a lesion that is more than 2 cm, endoscopic submucosal dissection (ESD) was developed. ESD therapy has now been established and is being used for early stage neoplastic lesions in the stomach, colon, esophagus, larynx and pharynx. In ESD specimens, we deal with relatively small lesions; therefore, more meticulous and precise pathological diagnosis is required compared to that in surgically resected specimens. In addition, we should be expert in the eligibility criteria of the different organs for ESD therapy. Here, we explain the biopsy diagnosis, including the Japanese group classification as well as the Vienna classification, handling the specimen, including fixation, photography, cutting and paraffin embedding, histological type, depth, vascular invasion and evaluation of the surgical margins, based on the latest Japanese guidelines. Japanese histopathology diagnostic criteria for the stomach, colon and esophagus are also described. We also demonstrate some examples of those mentioned above.

A comparative study on endoscopy treatment in rectal carcinoid tumors

BACKGROUND

To investigate the advantages and disadvantages of various endoscopic resection methods for rectal carcinoid tumors.

METHODS

A retrospective analysis of 3 types of endoscopic resection techniques for rectal carcinoid tumors was performed. The surgical time and the complication rate were compared between 30 patients who underwent conventional endoscopic mucosal resection (EMR), cap-assisted endoscopic mucosal resection (EMR-C), or endoscopic submucosal dissection (ESD). All rectal carcinoid tumors were under 1 cm and were treated in our center between January 2002 and January 2008.

RESULTS

Ten patients underwent each surgical approach. All cases were pathologically diagnosed as rectal carcinoid tumors. One-time complete resection rates using the conventional EMR, EMR-C, and ESD were 80%, 100%, and 100%, respectively. The operation time ranged from 5 to 53 minutes for the conventional EMR group, from 4 to 7 minutes for the EMR-C group, and from 16 to 35 minutes for the ESD group. The average follow-up time for the 30 patients was 18.43 ± 9.76 months. There were no recurrent or metastatic cases.

CONCLUSIONS

Endoscopic resection for rectal carcinoid tumors below 1 cm was safe. Considering the clinical efficacy, surgical time, and intraoperative complication rate, EMR-C may be the best endoscopic excision method.

[Endoscopic submucosal dissection: only for expert endoscopists?]

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.

Endoscopic submucosal dissection for esophageal granular cell tumor using the clutch cutter

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure associated with a high complication rate. The shortcomings of this method are the deficiencies of fixing the knife to the target lesion, and of compressing it. These shortcomings can lead to major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps (Clutch Cutter^®, Fujifilm, Japan) which can grasp and incise the targeted tissue using an electrosurgical current. Esophagogastroduodenoscopy on a 59-year-old Japanese man revealed a 16mm esophageal submucosal nodule with central depression. Endoscopic ultrasonography demonstrated a hypoechoic solid tumor limited to the submucosa without lymph node involvement. The histologic diagnosis of the specimen obtained by biopsy was granular cell tumor. It was safely and accurately resected without unexpected incision by ESD using the CC. No delayed hemorrhage or perforation occurred. Histological examination confirmed that the granular cell tumor was completely excised with negative resection margin.We report herein a case of esophageal granular cell tumor successfully treated by an ESD technique using the CC.

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.

New technique for safer endoscopic submucosal dissection using the duodenal balloon occlusion method

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) enables complete, collective removal of gastrointestinal (GI) malignant tumors, but requires a long operation time. Air insufflated during ESD is distributed throughout the entire GI tract, and thus causes an enlarged feeling of the abdomen. We aimed to reduce the incidence of an enlarged feeling of the abdomen by wedging a balloon in the bulbus duodeni to reduce air flow into the lower parts of the GI tract.

METHODS

Sixteen patients who were approved by the institutional ethics committee and provided consent to participate in this single-center, prospective study were divided into two groups using a sealed-envelope randomization method: ESD with a balloon wedged in the bulbus duodeni (the balloon [+] group) or conventional ESD with no balloon (the balloon [-] group). Total air volume in the entire GI tract and its change before and after ESD were measured objectively by 3-D computed tomography.

RESULTS

In the balloon (+) group, the mean intestinal gas volume (± standard deviation) was 274.3 ± 142.0 mL before ESD, and 352.5 ± 183.2 mL after, with a mean change of 78.1 ± 139.7 mL. The increase in intestinal gas volume was well controlled. No postoperative complications, such as an enlarged feeling of the abdomen, was reported in the balloon (+) group.

CONCLUSIONS

Our new technique has several advantages, including reduction in the frequency of postoperative abdominal symptoms, and will be useful and safe for gastric ESD.

Optical biopsies by confocal endomicroscopy prevent additive endoscopic biopsies before endoscopic submucosal dissection in gastric epithelial neoplasias: a prospective, comparative study

BACKGROUND

Confocal laser endomicroscopy (CLE) allows real-time in vivo histologic evaluation of GI lesions. To our knowledge, there is no reported prospective study comparing endoscopic and optical biopsy using CLE before endoscopic submucosal dissection (ESD) with post-ESD histopathology.

OBJECTIVE

We compared endoscopic and optical biopsy before ESD and thereby assessed the ability of CLE to effectively diagnose and differentiate gastric epithelial neoplasia.

DESIGN

Single tertiary-care center, prospective comparative study.

SETTING

Soonchunhyang University Hospital, between September 2009 and April 2010.

PATIENTS

This study involved 31 patients with 35 gastric epithelial neoplasias, previously diagnosed by endoscopic biopsy, who were scheduled for ESD.

INTERVENTION

Target lesions were imaged in vivo by using CLE.

MAIN OUTCOME MEASUREMENTS

The overall accuracy of endoscopic and CLE diagnosis was compared with post-ESD histopathology.

RESULTS

In histopathology after ESD, 11 of 35 lesions (31.5%) were adenomas and 24 (68.5%) were adenocarcinomas. The overall accuracy of CLE diagnosis of gastric adenomas and adenocarcinomas was significantly higher at 94.2% (95% confidence interval [CI], 81.3-98.4), versus 85.7% (95% CI, 70.6-93.7) for endoscopic biopsy (P = .031). The overall accuracy of CLE diagnosis of differentiated and undifferentiated adenocarcinomas also was higher (95.4%; 95% CI, 78.2-99.1) than that of endoscopic biopsy (84.2%; 95% CI, 62.4-94.4) but did not differ significantly (P = .146).

LIMITATIONS

Single tertiary-care center experience and small patient number.

CONCLUSION

This study demonstrates the high accuracy of diagnosis of gastric epithelial neoplasia by using CLE. The use of CLE could possibly thus reduce the number of unnecessary biopsies and mistaken diagnoses before ESD.

Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps)

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) was developed for en bloc resection of superficial neoplasm of the digestive tract. We evaluated feasibility and safety of ESD, as a salvage therapy of large refractory rectal polyps, in a tertiary care setting.

METHODS

We prospectively enrolled in the present study and treated by ESD 11 consecutive patients with rectal polyps (median diameter 3.5 cm; range 2-5 cm), who had previously undergone several attempts of endoscopic resection and not suitable for further standard endoscopic treatment. The ESD was carried out with a standard needle knife. Follow up examinations were scheduled at 3, 6, 12 and 24 months.

RESULTS

We achieved apparently complete resection of polyps in 10/11 patients. In one patient ESD was interrupted and the pathology of the resected fragment showed deep submucosal infiltration; this patient underwent surgery. Deep and lateral margins were shown to be free of neoplasm (radical resection) in six out of 11 patients. However all the 10 patients with apparently complete resection were free of recurrence after a mean follow up of 19.2 months (12-24). A T1 adenocarcinoma was radically resected by ESD, with no recurrence. We recorded 2 cases of subcutaneous emphysema, both treated conservatively.

CONCLUSIONS

Radical resection is difficult to be achieved by ESD in patients with rectal scar-embedded polyps. Nevertheless ESD may be proposed as a definitive treatment of selected patients with refractory polyps, avoiding surgery in the majority of them.

Full-thickness laparoendoscopic excision in the stomach: the FLEx technique

BACKGROUND

The authors describe the initial validation of a novel full-thickness laparoendoscopic excision (FLEx) technique for the stomach.

METHODS

The technique was studied in seven 50-kg pigs. Secure full-thickness excision was ensured by inversion excision target with a 1-cm circumferential margin using laparoendoscopically placed brace bars passed intraluminally from the outside of the stomach, laparoscopic oversewing of the site of inversion, and endoscopic full-thickness excision using a dual scope approach. Pigs were sacrificed either immediately (n = 3) or between 7 and 10 days after surgery (n = 4).

RESULTS

The procedure achieved uncomplicated full-thickness excision in every case. Median procedure duration was 227 minutes (range = 210-245 minutes). Median specimen diameter was 5.5 cm (range = 2.5-8 cm). Investigative autopsy confirmed technical sufficiency in all animals. Median site bursting pressure was 130 mm Hg (range = 120-160 mm Hg).

CONCLUSIONS

The FLEx technique proved useful for excision of small localized lesions of the stomach in this animal study.

Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

BACKGROUND

Endoscopic submucosal dissection (ESD) permits en bloc removal of superficial esophageal squamous cell carcinoma. However, postprocedure stricture is common after ESD for extensive tumors, and multiple endoscopic balloon dilation (EBD) is required for recalcitrant cases.

OBJECTIVE

To evaluate the effectiveness of oral prednisolone in controlling postprocedure esophageal stricture.

DESIGN

Retrospective study.

SETTING

Endoscopy department at a university hospital.

PATIENTS

Patients who underwent complete circular or semicircular ESD for esophageal squamous cell carcinoma involving more than three fourths of the lumen were treated with either pre-emptive EBD or oral prednisolone.

INTERVENTION

Preemptive EBD was started on the third day post-ESD and continued twice weekly for 8 weeks. Oral prednisolone was started at 30 mg/day on the third day post-ESD , tapered gradually, and then discontinued 8 weeks later. An additional EBD was performed on demand in both groups whenever dysphagia appeared.

MAIN OUTCOME MEASUREMENT

The incidence of esophageal stricture and number of EBD sessions required to relieve dysphagia.

RESULTS

Stricture at 3 months after ESD was found in 7 of 22 patients in the preemptive EBD group but only 1 of 19 in the oral prednisolone group (P < .05). The average number of EBD sessions required was 15.6 in the preemptive EBD group and 1.7 in the oral prednisolone group (P < .0001). After complete circular ESD, 32.7 EBD sessions were needed on average in the preemptive EBD group, whereas fewer were needed in the oral prednisolone group (P < .05).

LIMITATIONS

Nonrandomized study.

CONCLUSIONS

Post-ESD esophageal strictures were persistent even if treated preemptively with multiple EBD sessions, but oral prednisolone may offer a useful preventive option.

Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

Background

Endoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but is associated with esophageal stenosis, particularly when ESD involves the entire circumference of the esophageal lumen. We examined the effectiveness of systemic steroid administration for control of postprocedural esophageal stricture after complete circular ESD.

Methods

Seven patients who underwent wholly circumferential ESD for superficially extended esophageal squamous cell carcinoma were enrolled in this study. In 3 patients, prophylactic endoscopic balloon dilatation (EBD) was started on the third post-ESD day and was performed twice a week for 8 weeks. In 4 patients, oral prednisolone was started with 30 mg daily on the third post-ESD day, tapered gradually (daily 30, 30, 25, 25, 20, 15, 10, 5 mg for 7 days each), and then discontinued at 8 weeks. EBD was used as needed whenever patients complained of dysphagia.

Results

En bloc ESD with tumor-free margins was safely achieved in all cases. Patients in the prophylactic EBD group required a mean of 32.7 EBD sessions; the postprocedural stricture was dilated up to 18 mm in diameter in these patients. On the other hand, systemic steroid administration substantially reduced or eliminated the need for EBD. Corticosteroid therapy was not associated with any adverse events. Post-ESD esophageal stricture after complete circular ESD was persistent, requiring multiple EBD sessions.

Conclusions

Use of oral prednisolone administration may be an effective treatment strategy for reducing post-ESD esophageal stricture after complete circular ESD.

Usefulness of endoscopic ultrasound for the prediction of intraoperative bleeding of endoscopic submucosal dissection for gastric neoplasms

BACKGROUND AND AIM

Intraoperative bleeding is an important determining factor for the technical difficulty and safety of endoscopic submucosal dissection (ESD) for gastric neoplasms, which was previously difficult to predict before ESD. In the present study, we investigated whether endoscopic ultrasound (EUS) could be used to preoperatively predict intraoperative bleeding.

METHODS

The study included 106 patients who underwent EUS before ESD. EUS was used to evaluate the submucosal vascular structure. Patients who had at least 10 vascular structures per field of view or a vessel at least 500 µm in diameter were classified into the rich group (Group R), and others were classified into the non-rich group (Group N). The two groups were compared retrospectively with respect to procedure time, degree of anemia, frequency of clip use, and others.

RESULTS

There were 24 patients in Group R and 82 patients in Group N. Submucosal caner was found in 54.2% of patients in Group R and 18.3% in Group N. The reduction in hemoglobin was 5.8% in Group R and 3.45% in Group N. The procedure time was 151 min in Group R and 100 min in Group N. The frequency of clip use was 79.2% in Group R and 31.7% in Group N. A multivariate analysis revealed a significant difference in the depth of invasion and frequency of clip use between the two groups.

CONCLUSIONS

The results suggest that identification of submucosal vascular structure by EUS might allow prediction of intraoperative bleeding during ESD.

Successful type-oriented endoscopic resection for gastric carcinoid tumors: A case report

The standard treatment in Japan for gastric carcinoid has been gastrectomy with lymphadenectomy. This report describes the possibility of endoscopic treatment as an appropriate option for gastric carcinoid fulfilling certain conditions. A 46 year old woman underwent endoscopic mucosal resection for two 3 mm gastric carcinoids. The patient had hypergastrinemia with pernicious anemia and type A chronic atrophic gastritis, suggesting that the tumors were type I in Rindi's classification. Both tumors were located in the mucosal layer with no cellular polymorphism and were chromogranin A positive. Neither tumor recurrence in the stomach nor distant metastases have been documented during the 5 years of follow-up. Although many type I gastric carcinoids may be clinically indolent, reports on successful endoscopic treatment for this carcinoid have been scanty in the literature in Japan, presumably because of the hitherto surgical treatment stance for the disease. This report discusses how the size, number, depth and histological grading of the type I gastric carcinoid could allow the correct identification of a benign or malignant propensity of an individual tumor and how endoscopic resection could be a treatment of choice when these factors render it feasible. This stance could also obviate unnecessary surgical resection for more benign tumors.

Rectal laterally spreading tumors successfully treated in two steps by endoscopic submucosal dissection and endoscopic mucosal resection

BACKGROUND

Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy alternative to endoscopic mucosal resection (EMR) for superficial gastrointestinal neoplasms >2 cm. ESD allows for the direct dissection of the submucosa and large lesions can be resected en bloc. ESD is not limited by resection size, increases histologically complete resection rates and may reduce the local recurrence. Nevertheless, the technique is time-consuming, technically demanding and associated with a high complication rate. To reduce the risk of complications, different devices and technical advances have been proposed with conflicting results and, still, ESD en bloc resections of huge lesions are associated with increased complications.

CASE PRESENTATION

We successfully used a combined ESD/EMR technique for huge rectal laterally spreading tumors (LSTs). ESD was used for circumferential resection of 2/3 of the lesion followed by piecemeal resection (2-3 pieces) of the central part of the tumour. In all three patients we obtained the complete dissection of the polyp and the complete histological evaluation in absence of complications and recurrence at 6 months' follow up.

CONCLUSIONS

In the treatment of rectal LSTs, the combined treatment - ESD/EMR resection may be considered a suitable therapeutic option, indicated in selected cases as an alternative to surgery, in which the two techniques are neither reliable nor safe separately. However, to confirm our results, larger trials with longer follow up are required together with improvement of the technique and of the technical devices.

Endoscopic submucosal dissection for gastrointestinal lesions in the operating room: an analysis of 102 cases

AIM: To assess the efficacy and safety of endoscopic submucosal dissection (ESD) conducted in the operating room for gastrointestinal lesions.

METHODS: A total of 102 patients with gastrointestinal lesions diagnosed by endoscopy from March 2008 to May 2010 were enrolled. Chromoendoscopy and endoscopic ultrasonography were performed to confirm the extent and depth of the lesions. All the patients underwent routine preoperative evaluation. Tracheal intubation and general anesthesia were conducted in the operating room. The operation duration, volume of submucosal injection solution used, changes in blood Hb levels, and the rates of en bloc resection and complications were recorded.

RESULTS: The maximum diameter of resected samples was 2.72 cm ± 0.81 cm. The volume of submucosal injection solution used was 35.5 mL ± 14.05 mL. The average operation duration was 65.91 min ± 25.49 min. The en bloc resection rate was 95.1%. The perforation rate was 2.9%. Two patients received emergency surgery because of perforation and uncontrolled delayed hemorrhage.

CONCLUSION: ESD conducted in the operating room is associated with less complications and permits prompt, convenient handling of complications and avoiding medical risks.