Endoscopic Submucosal Dissection Using Mucosectome for Adenocarcinoma of Esophagogastric Junction and Gastric Cardia

Abstract

Introduction: Endoscopic submucosal dissection (ESD) procedure using IT knife, Hook knife, Flex knife, etc. has already reported and it is actually useful for En-bloc resection to some expert endoscopists of it, but sometimes difficult for general endoscopists to use it safely. When the target lesion is located at esophagogastric junction(EGJ) or gastric cardia(GC), ESD is quite difficult to carry out because the risk of complications such as bleeding and perforation is higher than the lesions at gastric body and antrum. The wall of EGJ and GC are thinner, and more thick vessels exist under the mucosa compared with gastric body and antrum. Therefore, surgery is the standard treatments for neoplasms located on EGJ and GC in many Japanese hospitals. We developed a safe and easy technique of the ESD using a new device (Mucosectome, Pentax Japan), and we have displayed our ESD technique for early esophageal caners using Mucosectome in DDW2006. This year, We studied our ESD method for superficial neoplasm located on EGJ and GC. Aims & Methods: Seventy-five lesions of superficial adenocarcinoma located on EGJ and GC were treated with ESD between July 2002 and September 2007 at Okayama university hospital and Tsuyama central hospital. Adenocarcinoma located on EGJ was defined as “true cardiac cancer (Type II)” and GC was defined as “subcardial gastric cancer (TypeIII)” according to Siewert's classification. We diagnosed “curative resection” based on the histological assessment after performing ESD; the lateral and vertical margins were free, differentiated type and mucosal or submucosal (less than 500 m from the musclaris mucosa) invasion. After ESD, the patients revealed “curative resection” usually underwent upper gastrointestinal endoscopy annually. For the patients revealed “non-curative resection”, surgical resection was carried out basically. In those patients, en-bloc resection rate, complications, curative resection rate, and procedure tine were evaluated. Results: En-bloc resection rate was 96%. Perforation occurred in two patients (1.3%) and both cases were managed conservatively by hemoclip. The average of the maximum size of resected specimen was 55.0 mm, and the average of the size of lesions was 13.5 mm. Sixty-five lesions (86.7%) were judged as “curative resection”. Four patients invaded more than 500 m in the submucosal layer were diagnosed as “non-curative resection” and underwent additional surgical resections. The maximum proceduer time was 180 minutes and the median of procedure time was 65 minutes. Conclusion: ESD using Mucosectome is useful and safe method for adenocarcinoma of esophagogastric junction and gastric ca.