Application Of Endoscopic Submucosal Dissection Research Articles

Endoscopic Evaluation and Management of Superficial Esophageal Squamous Cell Carcinoma

AbstractEsophageal squamous cell carcinoma (SCC) is the seventh most common malignancy and the sixth leading cause of cancer-related deaths globally, demanding precise diagnostic and individualized therapeutic interventions. This case study describes the diagnosis and treatment of esophageal SCC in a 54-year-old man initially detected during an upper gastrointestinal endoscopy. The lesion was identified using narrow-band imaging and magnifying endoscopy; after imaging studies, it was treated with endoscopic submucosal dissection (ESD). ESD is known for its minimal invasiveness and the definitive histopathological evaluation it facilitates.The management strategy described in this paper reiterates the criticality of extensive pretreatment evaluations, the indication of the application of ESD, and the importance of a multidisciplinary team. It underscores the significance of careful posttreatment monitoring and the informed selection of adjuvant therapies, particularly in areas like India, where such advanced endoscopic techniques are still on the rise.

Clinical application of endoscopic submucosal dissection for superficially invasive squamous cell carcinoma/high-grade squamous intraepithelial lesion involving the canal anal.

Superficially invasive squamous cell carcinoma (SISCC) and high-grade squamous intraepithelial lesions (HSIL) involving the anal canal are rare, and their surgical management involves local excision. Endoscopic submucosal dissection (ESD) has recently emerged as a promising treatment. This study aimed to evaluate the feasibility and safety of ESD for SISCC and HSIL in the anal canal. All patients diagnosed with SISCC or HSIL in the anal canal who underwent ESD between November 2018 and May2023 were included. Patient age, sex, pathology, human immunodeficiency virus (HIV) status, human papillomavirus (HPV) status, T stage, en bloc rate, and R0 resection rate were analyzed. Ten patients, including two men and eight women, with a median age of 61 (51-68) years were enrolled. All patients were HIV-negative, but five (50%) were HPV-positive. Pathological examination showed tumor stage of two patients as T2, one as T0 of SISCC, and seven as Tis of HSIL. The median specimen and tumor sizes were 24 (6-65) mm and 18 (6-55) mm, respectively. The en bloc and R0 resection rates were 100% and 80%, respectively. No severe complications occurred and no recurrence was observed at the follow-up (median follow-up period, 9 (1-35) months). ESD is a reliable and minimally invasive procedure that enables more individualized treatment options for specific groups. As we were limited by the length of the observation period, the long-term performance of ESD for SISCC and HSIL involving the anal canal requires further investigation.

Application of Endoscopic Submucosal Dissection (ESD) in treatment of gastrointestinal lesions- single center experience.

IntroductionEndoscopic resection of gastrointestinal tract lesions, originating from Japan, is becoming more frequently used in European countries. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) ensure minimally invasive removal of benign, premalignant and early neoplastic tumours of esophageus, stomach and intestine in selected group of patients.AimAim of this study was to determine the outcomes, radical resection rate (R0) and complication rate of ESD procedures performed in our department. Material and methodsThe data from 100 ESD procedures of esophageal, gastric, duodenal and colorectal lesions performed in out unit between 02.01.2020 and 30.06.2023 was collected and analysed retrospectively. Results42 male and 58 female patients in the median age of 64 years old (ranging 31 – 89 yo) underwent ESD. Mean duration of the procedure was 66 minutes (ranging 25 – 185 minutes). Tumours were located in oesophagus in 8 cases (8%), stomach in 25 cases (25%), duodenum in 1 case (1%) and colon in 66 cases (66%). Radical resection was achieved in 98 cases (98%) - 2 patients were qualified for surgical treatment Average size of dissection lesions was 26 x 19 mm. The biggest one was 60 x 60 mm (sigmoid adenoma) and smallest one was 5 x 5 mm (GNET). Complication occurred in 10 patients (10%) – 9 perforations of the wall of intestine (9%) and 1 hamorrhage, which required endoscopic intervention (1%). ConclusionsWith proper qualification, ESD is effective and safe method of treatment for benign, premalignant and early neoplastic lesions of gastrointestinal tract in hands of experienced endoscopists. Following current guidelines satisfying outcomes, comparable with leading center, can be achieved.

Management of esophageal neoplasms by endoscopic submucosal dissection: experience over 100 consecutive procedures.

Endoscopic submucosal dissection (ESD) is currently considered the first-line treatment for the eradication of superficial neoplasms of the esophagus in Eastern countries. However, in the West, particularly in Latin America, the experience with esophageal ESD is still limited because of the high technical complexity required for its execution. This study aimed to present the results of the clinical application of ESD to manage superficial esophageal neoplasms in a Latin American center in over 100 consecutive cases. This retrospective study included consecutive patients who underwent endoscopic ESD for superficial esophageal neoplasms between 2009 and 2022. The following clinical outcomes were assessed: en bloc, complete, and curative resection rates, local recurrence, adverse events, and procedure-related mortality. Esophageal ESD was performed mainly for squamous cell carcinoma (66.6%), high-grade intraepithelial neoplasia (17.1%), and adenocarcinoma (11.4%). En bloc and complete resection rates were 96.2% and 81.0%, respectively. The curative resection rate was 64.8%. Adverse events occurred in six cases (5.7%). Endoscopic follow-up was performed for an average period of 29.7 months. ESD performed by trained operators is feasible, safe, and clinically effective for managing superficial neoplastic lesions of the esophagus in Latin America.

Long-term outcome of cervical lymph node metastasis in superficial pharyngeal squamous cell carcinoma after endoscopic submucosal dissection

Superficial pharyngeal squamous cell carcinoma (PSCC) has received increasing attention as a therapeutic target in the GI field with recent innovations in endoscopic submucosal dissection (ESD). However, there are currently no defined criteria for the application of ESD to superficial PSCC. One of the problems encountered during follow-up after ESD is cervical lymph node metastasis (LNM). Identifying the clinicopathologic predictors of cervical LNM can help to provide a basis for the refinement of therapeutic strategies for superficial PSCC. The risk of cervical LNM was evaluated in 331 patients with superficial PSCC who underwent initial ESD between 2008 and 2021. Since tumor size, rather than depth, is the dominant factor in the current TNM classification for PSCC, the correlation between tumor size and thickness was investigated. The median follow-up period was 4.8 years. The cumulative 5-year cervical LNM rate was 6.1%. Multivariate Cox proportional hazards regression analysis identified tumor thickness≥1000 μm and lymphatic invasion as significant independent predictors. Among 204 cases with subepithelial invasion, both factors were also revealed to be significant independent predictors, suggesting that tumor thickness was superior to tumor size in predicting cervical LNM. Despite the positive correlation between tumor thickness and size, there was noticeable variability in the values (R= .20), and the current staging was inadequate to identify groups at high risk for cervical LNM. Tumor thickness and lymphatic invasion are validated as significant independent predictors for cervical LNM and can be useful indicators to optimize the therapeutic strategies for superficial PSCC.

Characteristics of metachronous gastric neoplasms after curative endoscopic submucosal dissection for early gastric neoplasms

Background:With the wide application of endoscopic submucosal dissection (ESD) for early gastric neoplasms, metachronous gastric neoplasms (MGN) have gradually become a concern. This study aimed to analyze the characteristics of MGN and evaluate the treatment and follow-up outcomes of MGN patients.Methods:A total of 814 patients were retrospectively enrolled. All these patients were treated by ESD for early gastric cancer or gastric dysplasia between November 2006 and September 2019 at The First Medical Center of Chinese People's Liberation Army General Hospital. The risk factors for MGN were analyzed using Cox hazard proportional model. Moreover, the cumulative incidence, the correlation of initial lesions and MGN lesions, and the treatment and follow-up outcomes of MGN patients were analyzed.Results:A total of 4.5% (37/814) of patients had MGN after curative ESD. The 3-, 5-, and 7-year cumulative incidences of MGN were 3.5%, 5.1%, and 6.9%, respectively, and ultimately reaching a plateau of 11.3% at 99 months after ESD. There was no significant correlation between initial lesions and MGN lesions in terms of gross type (P = 0.178), location (long axis: P = 0.470; short axis: P = 0.125), and histological type (P = 0.832). Cox multivariable analysis found that initial multiplicity was the only independent risk factor of MGN (hazard ratio: 4.3, 95% confidence interval: 2.0–9.4, P < 0.001). Seventy-three percent of patients with MGN were treated by endoscopic resection. During follow-up, two patients with MGN died of gastric cancer with lymph node metastasis. The disease-specific survival rate was significantly lower in patients with MGN than that in patients without MGN (94.6% vs. 99.6%, P = 0.006).Conclusions:The MGN rate gradually increased with follow-up time within 99 months after curative gastric ESD. Thus, regular and long-term surveillance endoscopy may be helpful, especially for patients with initial multiple neoplasms.

Effect of non-curative endoscopic submucosal dissection on short-term outcomes of subsequent surgery for early gastric cancer

BackgroundWith growing incidence of early gastric cancer (EGC), endoscopic submucosal dissection (ESD) is widely performed as a standard treatment for mucosal cancer. Due to the increasing application of ESD, the number of non-curative resection after ESD is also growing, leading to escalating number of patients who require additional gastrectomy with lymph node dissection after non-curative ESD. However, effects of ESD prior to surgery on technical difficulties during operation for EGC remain unclear. Therefore, this study aimed to determine the effect of non-curative ESD on short-term surgical outcomes in patients who underwent additional surgical treatment using propensity score matching method. MethodsTo evaluate the effect of ESD on short-term surgical outcomes in patients who underwent additional surgical treatment after a non-curative ESD procedure, patients were divided into two groups: (1) those who underwent additional gastrectomy after non-curative resection of ESD [ESD + Surgery (ES) Group], and (2) those who underwent gastrectomy as the initial treatment [Surgery Only (SO) Group]. To minimize differences in baseline demographic features that could potentially be associated with short-term outcomes, propensity-scored matching analysis was performed. ResultsAfter propensity-scored matching (1:1 matching), 140 patients altogether were selected and analyzed in this study. Complications were experienced by 18 (25.7%) patients in the ES group and 13 (18.6%) patients in the SO group, showing no significant (p < 0.416) difference between the two groups. ConclusionsAdditional surgery after non-curative ESD can be safely applied, even within one month after ESD in terms of short-term complications.

Application of endoscopic submucosal dissection in duodenal space-occupying lesions.

BACKGROUNDEndoscopic submucosal dissection (ESD) has been advocated by digestive endoscopists because of its comparable therapeutic effect to surgery, reduced trauma, faster recovery, and fewer complications. However, ESD for lesions of the duodenum is more challenging than those occurring at other levels of the gastrointestinal tract due to the thin intestinal wall of the duodenum, narrow intestinal space, rich peripheral blood flow, proximity to vital organs, and high risks of critical adverse events including intraoperative and delayed bleeding and perforation. Because of the low prevalence of the disease and the high risks of severe adverse events, successful ESD for lesions of the duodenum has rarely been reported in recent years.AIMTo investigate the efficacy and safety of ESD in the treatment of duodenal space-occupying lesions.METHODSClinical data of 24 cases of duodenal lesions treated by ESD at the Digestive Endoscopy Center of the Affiliated Hospital of Qingdao University from January 2016 to December 2019 were retrospectively analyzed.RESULTSAll of the 24 cases from 23 patients underwent ESD treatment for duodenal space-occupying lesions under general anesthesia, including 15 male and 8 female patients, with a mean age of 58.5 (32.0-74.0) years. There were 12 lesions (50%) in the duodenal bulb, 9 (37.5%) in the descending part, and 3 (12.5%) in the ball-descending junction. The mean diameter of the lesion was 12.75 (range, 11-22) mm. Thirteen lesions originated from the mucosa, of which 4 were low-grade intraepithelial neoplasia, 3 were hyperplastic polyps, 2 were chronic mucositis, 2 were adenomatous hyperplasia, 1 was high-grade intraepithelial neoplasia, and 1 was tubular adenoma. Eleven lesions were in the submucosa, including 5 neuroendocrine neoplasms, 2 cases of ectopic pancreas, 1 stromal tumor, 1 leiomyoma, 1 submucosal duodenal adenoma, and 1 case of submucosal lymph follicular hyperplasia. The intraoperative perforation rate was 20.8% (5/24), including 4 submucosal protuberant lesions and 1 depressed lesion. The mean length of hospital stay was 5.7 (range, 3-10) d, and the average follow-up time was 25.8 (range, 3.0–50.0) mo. No residual disease or recurrence was found in all patients, and no complications, such as infection and stenosis, were found during the follow-up period.CONCLUSIONESD is safe and effective in the treatment of duodenal lesions; however, the endoscopists should pay more attention to the preoperative preparation, intraoperative skills, and postoperative treatment.

Long-term outcomes of endoscopic submucosal dissection versus surgery for treating early gastric cancer of undifferentiated-type.

Application of endoscopic submucosal dissection (ESD) for treating undifferentiated-type early gastric cancers (EGCs) remains controversial. Therefore, we aimed to compare long-term outcomes of ESD with those of surgery for patients with undifferentiated-type EGCs by a retrospective study.We retrospectively reviewed data of patients who underwent curative ESD or gastrectomy for undifferentiated-type EGCs between 2010 and 2017. Gastric cancers were undifferentiated-type adenocarcinoma without ulceration confined to the mucosal layer and 2 cm or smaller in size. Demographics, complications, recurrence cancer rates, and survival data were collected and compared.Forty patients who underwent curative ESD and 52 patients who underwent surgery were included. The median follow-up duration was 74.6 months. There was no significant difference of metachronous gastric cancer rate (5.0% vs 3.8%, P = .75) or total cancer recurrence rate (10.0% vs 3.8%, P = .33) between the 2 groups. The 5-year overall survival, disease-free survival, recurrence-free survival rates did not significantly differ between the 2 groups (P = .72, .26, .27 respectively). There were no gastric cancer-related deaths in either group.Long-term outcomes after curative ESD for undifferentiated-type EGCs that met the expanded indication were comparable to that achieved with surgery. ESD without additional surgery is an acceptable choice to treat undifferentiated-type EGCs that meet the curative criteria.

Expanding the indication of endoscopic submucosal dissection for undifferentiated early gastric cancer is safe or not?

Endoscopic submucosal dissection (ESD) has gained more popularity in the treatment of early gastric cancer (EGC). Although there is a lack of confirmed evidence for the feasibility of ESD for undifferentiated EGC. The aim of the study was to investigate the feasibility of ESD with expanded indications for undifferentiated EGC patients. Data from patients with undifferentiated EGC (including signet-ring cell carcinoma, mucinous adenocarcinoma, mixed adenocarcinoma, and poorly differentiated adenocarcinoma) who underwent radical surgical resection were retrospectively reviewed. The relationship between the clinical parameters and the incidence of lymph node metastasis (LNM) was investigated. A total of 517 patients were included in this study. The results showed that LNM was significantly associated with ulceration, tumor size, depth of invasion, lymphatic invasion, vascular invasion, and perineural invasion. Multivariate stepwise logistic regression analysis revealed that tumor size (OR=1.61, 95% CI=1.03-2.52, P=0.0367), depth of tumor invasion (OR=2.77, 95% CI=1.66-4.63, P=0.0001), and lymphatic invasion (OR=14.74, 95% CI=1.58-137.36, P=0.0182) were independent risk factors for LNM. In the patients who would be included under the new proposed guidelines for ESD, including men with mucosal tumors ≤2cm and without ulceration or lymphatic or venous infiltration, LNM was present in 11.9% (14/118). Caution to be exercised in expanding application of ESD should be carefully weighed in undifferentiated EGC.

Preliminary results of endoscopic submucosal dissection in Vietnamese patients with gastric pre-neoplasia lesion.

91 Background: Gastric cancer is in the top three most common cancers in Vietnam and the disease is mainly detected in late stage. There is a lack of evaluation of the pre-neoplasia stage of gastric cancer and selection an appropriate and effective treatment remains still in debate. Hence, the study aims to evaluate, for the first time, the safety and efficacy of the application of endoscopic submucosal dissection (ESD) technique on Vietnamese patients with pre-neoplasia lesion in stomach. Methods: We included all patients diagnosed with lower or high-grade gastric dysplasia and hopitalized in the Department of Endoscopic and Functional Exploration in K Hospital from March 2018 to June 2019. Eligible patients were applied by the ESD technique as the standard treatment. We evaluated the efficacy and safety of after the intervention of ESD by the neoplasia recurrence rate after 3 months and the occurrence of adverse events during and after the ESD procedure described in frequency and percentage. Results: During the investigational period, we chose 65 pre-neoplasia gastric patients for the application of ESD technique. The male/female ratio was 1.09 and the mean age of patients was 58.07 years. The duration of hospitalization was about 3 days. We found 57 patients (87.69%) with location of the lesions in pylorus. The average of tumor sizes was 20.46 mm. All patients were treated with curative en bloc resection and no case was found as failure. Out of 65 patients, we found 2 patients (3%) with bleeding complication, no perforation and other post-surgery complication were identified. The average of procedure time was short (67.53 minutes). The histopathological specimen results revealed that 20 patients (30.76%) were diagnosed as cancer and 40 patients (61.53%) were diagnosed as high-grade dysplasia, all patients had a margin negative after ESD. After 3 months of treatment, all patients have no pre-neoplastic recurrence. Conclusions: Our result showed that the ESD technique is relatively safe and effective for Vietnamese patients with pre-neoplasia at stomach.

909 Endoscopic Mucosal Resection versus Endoscopic Submucosal Dissection in the Treatment of Superficial Gastric Cancers - A Meta-Analysis Update

INTRODUCTION: Early gastric cancer (EGC) is defined as a malignant tumor confined to the mucosa or the submucosa regardless of lymph node metastases. Endoscopic Mucosal Resection (EMR) is widely accepted as the treatment modality for EGC although it has some limitations. To overcome these and to facilitate resection of difficult lesions, Endoscopic Submucosal Dissection (ESD) was developed. ESD has a higher En-bloc and histological resection rate when compared to EMR. However, when compared to EMR, ESD has a higher complication rate, longer duration and is technically challenging. Despite its wide use in Eastern countries, the application of ESD is still being debated in the United States. We conducted a meta-analysis comparing the efficacy and safety of EMR and ESD in the management of EGC. METHODS: A literature search was done from electronic databases including PubMed, Cochrane, and Embase from inception until November 2018. A total of 13 relevant studies were isolated and included in the study. The relevant data were extracted, and meta-analysis with Random effects model was done using RevMan 5.3. RESULTS: We had a total of 3807 lesions in the EMR group and 4284 lesions in the ESD group. Patient characteristics were available for only 8 studies and were age-matched with a mean age of 67.15 years [Male-76.9%, Female-23.1%] and 67.52 years [Male-76.7%, Female-23.3%] in EMR and ESD groups respectively. Our primary outcomes were en-bloc resection rate (EBR) and curative resection rate (CRR). 2171 lesions were removed en-bloc by EMR versus 3949 lesions by ESD [OR 8.14, 95%CI (6.08, 10.91), P &lt; 0.0001, I2 = 71%], favoring ESD over EMR. The CRR was achieved in 3194 lesions with ESD as compared to 1890 lesions with EMR [OR 4.23, 95%CI (2.61, 6.85), P &lt; 0.00001, I2 = 91%]. Complications including bleeding [OR 0.65, 95%CI (0.43, 0.98), P = 0.04, I2 = 54%] and perforation [OR 0.40, 95%CI (0.24, 0.68), P = 0.0006, I2 = 50%] were significantly higher with ESD over EMR. CONCLUSION: This meta-analysis shows that EBR and CRR are better achieved with ESD over EMR, with higher rates of bleeding and perforation with ESD. ESD is a complex procedure requiring a high level of expertise, training, and its success depends on the performer’s skills. With careful selection of patients and advanced endoscopic skills, outcomes could be better with ESD than EMR. Our study has limitations; the data used for the analysis were non- randomized and were conducted in heterogeneous practice settings.

Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer

Objective: This study aimed to identify clinicopathological factors predictive of lymph node metastasis in patients with the poorly differentiated early gastric cancer (EGC) to assess the feasibility of using endoscopic submucosal dissection (ESD). Methods: The records of patients with poorly differentiated early gastric cancer undergoing gastric radical resection between January 2012 and December 2016 were reviewed in Ruijin hospital. Those with distant metastasis, two or more malignant tumors, remnant gastric cancer, neo adjuvant therapy, previous history of gastric surgery or clear history of perigastric lymphadenectomy, and mixed tumors were excluded. Age, sex, presence of ulcerous lesion, tumor size, tumor location, depth of invasion, type of differentiation, lymphatic vessel invasion, vascular invasion, nerve invasion and HER2 expression were collected. Univariate and multivariate stepwise logistic regression analyses were used to identify the independent risk factors of perigastric lymph node metastasis.According to the Guidelines for the Treatment of Gastric Cancer (2018 edition) of the Chinese Society of Clinical Oncology (CSCO), the expanded indications of ESD for EGC are as follows: (1)no ulcerative lesions, the maximum diameter of lesions >2 cm of differentiated intramucosal cancer; (2)ulcerative lesions, the maximum diameter of lesions ≤3 cm of differentiated intramucosal cancer; (3)no ulcerative lesions, undifferentiated intramucosal carcinoma with diameter ≤2 cm. The relationship between clinicopathological factors and lymph node metastasis was analyzed. Results: A total of 517 patients, aged 21-83 (57.1±11.7), including 307 males and 210 females, were enrolled in the study. Among them, 114 (22.0%) patients had lymph node metastasis. Univariate analysis showed that ulcerative lesion (P=0.042), tumor diameter (P=0.048), depth of invasion (P<0.001), location of tumors (P<0.001), lymphatic vessel invasion (P=0.009), vascular invasion (P<0.001) and nerve invasion (P=0.028) were related to lymph node metastasis after radical resection of poorly differentiated early adenocarcinoma. Age, sex, type of differentiation and HER2 expression were not significantly correlated to lymph node metastasis (P>0.05). Multivariate analysis showed that tumor size (OR=1.61, 95% CI: 1.03-2.52, P=0.037), depth of invasion (OR=2.77, 95% CI:1.66-4.63, P<0.001), lymphatic duct invasion (OR=14.74, 95% CI:1.58-137.36, P=0.018) were independent risk factors for lymph node metastasis in poorly differentiated EGC, and ulcerative lesion was not a risk factor for lymph node metastasis (OR=0.82, 95% CI:0.56-1.18,P=0.285). A total of 119 patients with poorly differentiated EGC fully complied with the relative indications of ESD recommended by the Japanese Statute and the criteria for radical resection after ESD. Among them, 14 (11.8%) still had perigastric lymph node metastasis, while the gender, tumor diameter, location, differentiation and HER2 expression were not associated with lymph node metastasis (P>0.05). Conclusion: For patients with poorly differentiated EGC, the application of ESD should be carefully weighed with precise assessment of tumor diameter, depth of invasion, and lymphatic duct invasion.

Propofol Sedation in the Endoscopy Room versus Operation Room during Endoscopic Submucosal Dissection for Gastric Tumors: A Propensity Score-Matching Analysis

Background/Aims: The present study was performed to compare the safety of sedation with propofol during endoscopic submucosal dissection (ESD) for gastric tumors under sedation in the endoscopy room by an endoscopist versus sedation in the operation room by an anesthesiologist. Methods: In total, 638 patients with gastric tumors who underwent ESD from January 2011 to August 2017 at Ureshino Medical Center and Saga Medical Center Koseikan were retrospectively reviewed. The patients were divided into 2 groups: those who underwent ESD in the endoscopy room (Group E, n = 532) and those who underwent ESD in the operation room (Group O, n = 106). Propensity score matching was applied for evaluation. The treatment outcome of ESD and the adverse events of sedation during ESD (desaturation, hypotension, bradycardia, and arrhythmia) were compared between the 2 groups to consider the safety of ESD. Results: The propensity score-matching analysis created 82 matched pairs. Adjusted comparisons between Groups E and O showed similar treatment outcomes of ESD for gastric tumors. There were no significant differences in the treatment outcomes, anesthesia time, and mean propofol dose between the 2 groups. With respect to adverse events, desaturation occurred more often in Group E than Group O (18.3 vs. 3.7%, respectively; p = 0.005). There were no significant differences in other adverse events (hypotension, bradycardia, and arrhythmia) between the 2 groups. Conclusion: Sedation with propofol in the operation room might be required to ensure safer application of ESD for gastric tumors. However, a decrease in the desaturation rate was the only disadvantage of sedation in the endoscopy room.

Endoscopic Submucosal Dissection for Esophageal Adenocarcinoma: A North American Perspective

BackgroundData are limited regarding the application of endoscopic submucosal dissection (ESD) in Western countries or for esophageal adenocarcinoma in any part of the world. We sought to review our experience employing ESD in patients with early esophageal cancer at a high volume North American esophageal cancer treatment center. MethodsA prospectively maintained database of all patients with esophageal cancer treated at the McGill University Health Center was used to identify ESDs performed for adenocarcinoma between 2012 and 2016. Patient demographics, pre-resection tumor characteristics, endoscopic resection technical variables, pathologic results, and short- and long-term outcomes were recorded. ResultsOf 650 patients in the database, 26 underwent 27 procedures. The majority (67%) had pre-treatment EUS. There were no post-ESD bleeding events requiring re-intervention. Perforation occurred in 2/27 (7%), one of which required operative repair. Complete RO resection was achieved in 18/27(67%). Salvage laparoscopic esophagectomy was performed in six patients. At a median follow-up of 18.5 (7–35) months, cancer recurrence occurred in only one patient who subsequently underwent successful repeat ESD. ConclusionsAlthough technically challenging, ESD represents a safe and effective treatment of early esophageal adenocarcinoma and has the potential to become a more important tool in management of these early lesions in Western countries.

Endoscopic diagnosis and management of early squamous cell carcinoma of esophagus

In recent years, diagnosis of early squamous cell carcinoma (SCC) of the esophagus has been increasingly emphasized. Utilization of image enhanced technology such as narrow band imaging (NBI) and magnification endoscopy allowed detailed examination of the esophageal mucosa. Different patterns of intrapapillary capillary loops (IPCL) have been proven to accurately diagnose and predict the depth of invasion of the tumors. In addition, the application of endoscopic submucosal dissection (ESD) has enabled safe en bloc resection of esophageal lesions. Promising results of ESD have been published and ESD is now the standard of therapy in early SCC of esophagus.

The superficial elevated and depressed lesion type is an independent factor associated with non-curative endoscopic submucosal dissection for early gastric cancer.

The expanded criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) have led to an increase in the number of EGC patients who receive curative treatment involving endoscopic techniques. Identifying the factors that are associated with treatment outcomes would be helpful in the application of ESD for EGC. Potential factors associated with incomplete ESD and with non-curative ESD were investigated using a multiple logistic regression model in EGC patients who consecutively underwent ESD according to the expanded criteria. A total of 363 patients with 398 EGC lesions were enrolled. The rates of complete ESD and curative ESD were 96.2% (383/398) and 85.7% (341/398), respectively. No significant factors associated with incomplete ESD were identified. In contrast, a tumor size >20mm [odds ratio (OR) 3.31; 95% confidence interval (CI) 1.74-6.29], the superficial elevated and depressed type (0-IIa+IIc or IIc+IIa) (OR 4.37; 95% CI 1.88-9.88), and the undifferentiated type (OR 5.93; 95% CI 1.65-19.41) were identified as independent factors associated with non-curative ESD. The superficial elevated and depressed type in particular was found to be highly related to submucosal and lymphovascular invasion. The rate of non-curative ESD in cases of this macroscopic type occurring together with a tumor size >20mm was 58.3%, and the adjusted OR was 16.48 (95% CI 4.69-62.09). The results suggest that the superficial elevated and depressed type is an independent factor associated with non-curative ESD and that the risk of non-curative ESD is increased when this macroscopic type is present along with a large tumor size.

Tu1704 Clinical Outcomes of Endoscopic Submucosal Dissection for Undifferentiated Early Gastric Cancer: Retrospective Analysis

Endoscopic submucosal dissection (ESD) is accepted as a standard treatment for selected patients with early gastric cancer (EGC). However, the application of ESD for undifferentiated EGC was controversial. The aim of this study was to evaluate the clinical outcomes in patients with undifferentiated EGC.

Towards safer and appropriate application of endoscopic submucosal dissection for T1 colorectal carcinoma as total excisional biopsy: future perspectives.

According to the Japanese Society for Cancer of the Colon and Rectum Guidelines 2014 for the Treatment of Colorectal Cancer, cases with T1 colorectal carcinoma should be considered for additional colectomy with lymph node dissection when histologically complete en bloc resection is endoscopically carried out and when one of the four risk factors listed below is present. These four risk factors are: (i) submucosal (SM) invasion depth ≥1000 μm; (ii) positive vascular invasion; (iii) poorly differentiated adenocarcinoma, signet ring cell carcinoma, or mucinous carcinoma; and (iv) grade 2/3 budding at the deepest part of SM invasion. However, the probability of lymph node metastasis is extremely low if none of these risk factors are present, with the exception of SM invasion depth ≥1000 μm. Consequently, it is assumed that there will be an increasing number of cases where no additional surgery is done, or cases of moderate invasive carcinoma in which endoscopic treatment is carried out to achieve an excisional biopsy, for which complete resection is applicable. In these cases, the preoperative diagnosis, resection techniques such as endoscopic submucosal dissection, features of resected specimens, and the accuracy of pathological diagnosis are all extremely important.

Influence of endoscopic submucosal dissection on additional gastric resections.

Widespread application of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) results in noncurative resection in some patients. The influence of preceding ESD on additional gastric resections has not been completely evaluated. Endoscopic, surgical, and pathological records of 255 patients who underwent additional gastrectomy after noncurative ESD at a single prefectural cancer center from September 2002 to December 2010 were reviewed. The estimated gastric resection based on endoscopic images before ESD was compared with the actual gastric resection performed after ESD. Altered gastric resection was performed in 4 (1.6%) of the 255 patients. In 3 patients, total gastrectomy was performed instead of distal gastrectomy; in 1 patient, distal gastrectomy was performed instead of pylorus-preserving gastrectomy because of an insufficient distance from the cardia or pylorus caused by contraction of the ESD scar. Standard gastrectomy including total or distal gastrectomy with D2 lymph node dissection was performed in 33 patients because of deep submucosal invasion with positive/indefinite vertical margins. The final pathology revealed pT2 or deeper in 10 patients. In conclusion, 98.4% patients underwent the scheduled gastric resection before ESD, and the preceding gastric ESD had almost no influence on changing the gastric resection of the additional surgery. Although rare, the preceding ESD may necessitate alterations in gastric resection to widen the surgical area because of contraction of ESD scar for lesions near the cardia or pylorus. MINI ABSTRACT: A retrospective study of additional gastrectomy after noncurative ESD showed that the preceding ESD had almost no influence on changing the gastric resection of the additional surgery.