Development Of Endoscopic Submucosal Dissection Research Articles

Preoperative Diagnosis and Indications for Endoscopic Resection of Superficial Esophageal Squamous Cell Carcinoma.

Endoscopic resection (ER) is the mainstay of treatment for superficial esophageal squamous cell carcinoma (SESCC) instead of esophagectomy because of its minimal invasiveness and favorable clinical outcomes. Developments in endoscopic submucosal dissection have enabled en bloc resection of SESCCs regardless of size, thus reducing the risk of local recurrence. Although ER for SESCC is effective, metastasis may subsequently occur. Additionally, extensive esophageal ER confers a risk of postoperative esophageal stricture. Therefore, accurate assessment of the invasion depth and circumferential extent of SESCCs is important in determining the indications for ER. Diagnostic accuracies for SESCC invasion differ between epithelial (EP)/lamina propria (LPM), muscularis mucosa (MM)/submucosal (SM1), and SM2 cancers. ER is strongly indicated for clinically diagnosed (c)EP/LPM cancers because 90% of these are as pathologically diagnosed (p)EP/LPM, which has a very low risk of metastasis. Remarkably, the diagnostic accuracy for cMM/SM1 differs significantly with lateral spread of cancer. Eighty percent of cMM/SM1 cancers with ≤3/4 circumferential spread prove to be pEP/LPM or pMM/SM1, which have very low or low risk of metastasis. Thus, these are adequate candidates for ER. However, given the relatively low proportion of pEP/LPM or pMM/SM1 and high risk of subsequent stricture, ER is not recommended for whole circumferential cMM/SM1 cancers. For cMM/SM1 cancers that involve >3/4 but not the whole circumference, ER should be considered on a lesion-by-lesion basis because the risk of post-ER stricture is not very high, but the proportion of pEP/LPM or pMM/SM1 is relatively low. ER is contraindicated for cSM2 cancers because 75% of them are pSM2, which has high risk of metastasis.

Advances in Endoscopic Resection in the Management of Esophageal Neoplasia

There has been a paradigm shift in the management of early-stage cancer and benign submucosal lesions in the esophagus over the last 30 years. Previous conditions that required either full or partial esophagectomy can now be managed with endoscopic resection techniques, with superior adverse event and comorbidity profiles compared with surgery. Though cap-assisted endoscopic mucosal resection heralded the development of non-surgical therapies, this technique is limited by the size of the lesion, with larger lesions requiring piecemeal resection leading to lack of clear margins. The development of endoscopic submucosal dissection affords the ability to precisely remove lesions en bloc, allowing for a full pathologic evaluation of excised tissue. The developments of specialized coagulating “knives,” as well as the utilization of traction techniques, have enhanced the efficiency and safety of this procedure. Submucosal tunneling, submucosal excavation, and full-thickness resection techniques have also broadened the indications for which endoscopic resection can be performed. Lastly, the development of robot-assisted devices has afforded a wider range of dissecting angles, allowing for more precise resection of esophageal lesions that may have been difficult to resect previously. Advances in endoscopic resection techniques have afforded a non-invasive method for the management of benign and malignant esophageal lesions, with proven efficacy and safety profiles.

Endoscopic or Surgical Resection for Gastro-Esophageal Cancer.

Early gastro-esophageal cancer is staged as m1 to m3 depending on the infiltration of the anatomical layers of the mucosa or, analogously, as sm1 to sm3 depending on the depth of infiltration into the submucosa. The risk of lymph node metastases is low in mucosal carcinoma but increases with the depth of infiltration into the submucosa. This review is based on pertinent publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and the International Standard Randomised Controlled Trial Number (ISRCTN) registry. New technologies such as narrow-band imaging have improved the endo- scopic diagnosis and staging of early gastro-esophageal cancer. The development of endoscopic submucosal dissection has led to a higher R0 resection rate, a lower risk of recurrence, and an increase in the number of endoscopic resections that are performed with curative intent. In squamous-cell carcinoma of the esophagus, surgical oncological esophagectomy is indicated if the cancer infiltrates into the third mucosal layer (T1a, m3) or deeper. In esophageal adenocarcinoma, the prevalence of lymph node metastases is low if the cancer is restricted to the mucosa and in- creases only when the submucosa is infiltrated. In the current German S3 guideline, endoscopic resection is recommended for intramucosal adenocarcinoma as long as there are no further histopathological risk factors. Lymph node metastasis in gastric carcinoma begins in the deep mucosal infiltration stage (m3). If certain special con- ditions ("extended criteria") are met, carcinoma expanding into the first submucosal layer (sm1) can be removed endoscopically. All further stages must be treated with total or subtotal gastrectomy with systematic D2 lymphadenectomy. Borderline cases between endoscopic and surgical resection of early carcinoma of the esophagus or stomach must be managed with an interdisciplinary treatment algorithm. If there is a risk of lymph node metastasis, surgical oncological resection is indicated. Such resections of gastroesophageal cancer in the locally advanced stage should always be part of a multimodal treatment approach.

Primary malignant melanoma of the esophagus treated by endoscopic submucosal dissection: A case report.

Primary malignant melanoma of the esophagus (PMME) is a rare malignant neoplasm of the esophagus. In the majority of cases, the disease originates in the mucosal layer of the esophagus, which is similar to other types of esophageal cancer. With the development of endoscopic submucosal dissection (ESD), endoscopic resection is possible for cases in which melanomas are limited to the mucosal and submucosal layer. However, few studies report the efficiency of ESD for PMME, and no studies perform long-term follow-up. The present study reported the case of a 71-year-old PMME patient who was successfully treated by ESD at The Third Affiliated Hospital of Soochow University (Changzhou, China) in Otober 2011, with a follow-up of >3 years conducted.

Application of hydrogels as submucosal fluid cushions for endoscopic mucosal resection and submucosal dissection.

Numerous new techniques have recently been reported and described for the endoscopic mucosal resection (EMR) of large superficial lesions of the gastrointestinal tract, using various natural, synthetic, and semi-synthetic materials such as chitin/chitosan and their derivatives. Although saline-assisted EMR is an established minimally invasive therapy, en bloc resection and histopathological analyses are required to determine its curative potential. In addition, complete resection of lesions of >2 cm in diameter remains difficult, despite improved EMR techniques. The development of endoscopic submucosal dissection (ESD) has increased dissection rates for en bloc resection of large lesions, but perforation occurs more frequently during ESD than during EMR. Submucosal injections of those biomaterials which have high viscosity and hydrogelatinization ability as submucosal fluid cushions (SFC) may facilitate ESD as well as EMR for the treatment of superficial tumors of the alimentary tract. In this review, we describe the application of biomaterials such as chitosan derivatives, sodium hyaluronate, and 50% glucose as a SFC for ESD, focusing photocrosslinked chitosan hydrogels (PCH) which we have originally developed.

Suitability of the expanded indication criteria for the treatment of early gastric cancer by endoscopic submucosal dissection: Japanese multicenter large-scale retrospective analysis of short- and long-term outcomes

Objective. The criteria for endoscopic resection for early gastric cancer include absolute and expanded indications. Consensus already exists for the absolute indications. However, the suitability of the expanded indications must be validated by long-term outcome analyses since such lesions have only recently become resectable with the development of endoscopic submucosal dissection. The aim of this study is to clarify the suitability of the expanded indications for the treatment of early gastric cancer with endoscopic submucosal dissection. Materials and methods. The medical records of 1161 patients with early gastric cancers (1332 lesions) treated by endoscopic submucosal dissection and meeting the criteria for absolute or expanded indications without additional treatment with gastrectomy were divided into absolute indication group or expanded indication group. Results. Complete resection rates were 96.4% and 93.4% in absolute and expanded indication groups, respectively, with no significant differences between the groups. Delayed bleeding rates were significantly higher in the expanded indication group, whereas all cases were successfully managed conservatively. The 5-year overall survival and recurrence-free rates were 93.7%/99.77% and 90.49%/98.90% in the absolute and the expanded indication groups, respectively, with no significant differences between the groups for either measure. Multivariate analyses revealed that affected horizontal margin and tumor location were independent predictive factors for recurrence. Conclusion. The expanded indication group showed excellent post-endoscopic submucosal dissection short-term and long-term outcomes compared with the absolute indications group, demonstrating that expanded indications are suitable for endoscopic submucosal dissection for early gastric cancer.

Tu1572 Endoscopic Submucosal Dissection for Widespread Superficial Esophageal Neoplasm Doesn't Increase the Incidence of Perioperative Complication Except for Esophageal Stricture

With the development of endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, removing the widespread lesion in one piece has become possible. On the other hand, widespread mucosal defect after endoscopic resection causes severe postoperative stricture formation. And then, ESD for widespread lesion is thought to be a risky procedure and related with many perioperative complications. However, there were few reports about the complication of widespread esophageal ESD except for postoperative stricture, and the safety of the procedure was not fully assessed.

Efficacy of Propofol Sedation for Endoscopic Submucosal Dissection (ESD): Assessment with Prospective Data Collection

The indications for endoscopic treatment in early stage cancer of the digestive tract are expanding with the emergence and technical development of endoscopic submucosal dissection (ESD). ESD requires longer term stable sedation than conventional endoscopic procedures due to the necessity of meticulous control of the devices during the procedure. Propofol has a very short half-life and can be administered continuously, which is advantageous for long-term sedation. Propofol, thus, is likely to be useful for sedation during ESD. Fifty consecutive patients who underwent ESD for early gastric cancer with propofol sedation (Group P) and those with midazolam sedation (Group M) were included in this study. Cardiorespiratory suppression rate and the condition of arousal were compared between the groups. A questionnaire survey on the satisfaction of endoscopists, anesthesiologists, endoscopy nurses, and ward nurses with the use of propofol was also carried out. Respiratory suppression was observed in 50% in Group M and in 20% in Group P (p<0.05). Hypotension was seen in 14% and 36% in Groups M and P, respectively (p<0.05). No sedation-related complications were encountered in either of the groups. Arousal rates 1 hour and 3 hours after the procedure were 23% and 60% in group M and 86% and 100% in Group P (p<0.05). As for the questionnaire survey, most respondents, in particular the ward nurses, supported the use of propofol. Our data suggest that propofol is safe and useful during ESD as compared with midazolam.

THE NEW RESOURCES OF TREATMENT FOR EARLY STAGE COLORECTAL TUMORS: EMR WITH SMALL INCISION AND SIMPLIFIED ENDOSCOPIC SUBMUCOSAL DISSECTION

Early stage colorectal tumors can be removed by endoscopic mucosal resection (EMR) but larger tumors (> or =20 mm) may require piecemeal resection. The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of lesions regardless of size and shape. However ESD of colorectal tumor is technically difficult. As the resources, we perform EMR with small incision (EMR with SI) for more reliable EMR, and also ESD with snaring (simplified ESD) for easier and safer ESD. AIM & METHODS: The aim of the study was to retrospectively compare the treatment results of the following 3 methods (EMR with SI/ simplified ESD/ ESD). We treated 24/44/468 colorectal tumors, and examined the tumor size, resected specimen size, procedure time, en-bloc resection rate, complication rate. The median tumor size (mm) (EMR with SI/simplified EMR/ESD) was 20/17/30 (EMR with SI vs simplified ESD: P = n.s, simplified ESD vs ESD: P < 0.0001). The median resected specimen size (mm) was 22.5/26/41 (EMR with SI vs simplified ESD: P = 0.0018, simplified ESD vs ESD: P < 0.0001). The procedure time (min.) was 19/27/60 (EMR with SI vs simplified ESD: P = n.s, simplified ESD vs ESD: P < 0.0001) The en-bloc resection rate (%) was 83.3/90.9/98.9. The complication rate (post-operative bleeding rate/perforation rate) was 0/0, 2.3/4.5, 1.5/1.5 (simplified ESD vs ESD: P = n.s). Endoscopic mucosal resection with small incision (EMR with SI) and ESD with snaring (simplified ESD) are a good option to fill the differences between conventional EMR and ESD, and also considered to become nice steps to the introduction of ESD.

Ulcerous Change Decreases the Accuracy of Endoscopic Ultrasonography Diagnosis for the Invasive Depth of Early Gastric Cancer

With the development of endoscopic submucosal dissection, an expansion of the criteria for local treatment was suggested for lesions with ulcerous changes or undifferentiated-type adenocarcinoma. To determine the efficacy of endoscopic ultrasonography for such lesions, we retrospectively analyzed factors that influenced accurate diagnosis by endoscopic ultrasonography of the depth of tumor invasion. We investigated 267 gastric adenocarcinomas for which histopathological results were obtained by endoscopic mucosal resection or gastrectomy. The lesions were divided into four groups by histological type and the presence of ulcerous changes. Five clinicopathological factors were assessed for their possible associations with incorrect diagnosis. The positive predictive value (PPV) for cancer limited within the mucosa (endoscopic ultrasonography, EUS-M) and cancer invaded into the submucosal layer (EUS-SM) were 88.0% (125 of 142 lesions) and 60.0% (30 of 50 lesions), respectively. The lesions diagnosed as EUS-M/SM borderline (37 lesions) included 19 lesions (51.4%) of M cancer and 17 lesions (45.9%) of SM cancer. In logistic analysis, ulcerous changes (p < 0.0001) and macroscopic classification (p = 0.0284) were factors that caused incorrect diagnosis by endoscopic ultrasonography. In the group having differentiated-type adenocarcinoma with ulcerous changes, the PPV of EUS-SM was 25% (3 of 12), and there was a significant difference (p < 0.05) between the EUS-SM of this group and that of the differentiated-type adenocarcinoma without ulcerous changes. The accuracy of endoscopic ultrasonography tumor staging was not sufficient for the lesions with ulcerous changes in our study. Therefore, we should be careful to perform endoscopic submucosal dissection for lesions with ulcerous changes.

Effectiveness of Endoscopic Submucosal Dissection Using Flush Knife for Esophageal Cancers

Introduction: The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of lesions regardless of size and shape. However, ESD is associated with a high level of technical difficulty and a high incidence of complications. In order to perform ESD more easily, safely, and efficiently, we invented water jet short needle knives (FlushKnife). Aims & Methods: We have developed FlushKnife with Fujinon having a tip portion with five projection length of 1, 1.5, 2, 2.5 and 3 mm that can emit a jet of water from the tip of a sheath. We treated 62 lesions in 52 patients (54 intramucosal cancers, 8 submucosal cancers) with ESD using FlushKnife between March 2005 and October 2006. VIO 300D (ERBE) was used for a electro surgical generator, and a 4-mm length attachment was put on the endoscope tip in order to treat as below. We marked around the lesions using 1 mm type of FlushKnife with forced coagulation mode 20w, effect 3, and performed the mucosal incision of the entire circumference using 2 mm with endo-cut I mode. Then, we dissected submucosal layer using 1, 1.5 or 2 mm with forced coagulation mode 40w, effect 2. A Hook knife was also used in situations where muscle layers were located in front. Results: En-bloc resection was performed in 61(98.4%) cases. Complete resection performed in 61 (98.4%) cases. The median size of resected specimen was 45 mm (23-80 mm) and that of tumors was 23 mm (3-72 mm). The median time of procedure was 43 minutes (20-206 minutes). Complications: No perforation was observed. All spurting bleeding were stopped by hemostatic forceps. No patients needed blood transfusion. Conclusion: Complete resection rate of ESD using FlulshKnife is extremely high and complication rate of that is low. Shortening of the projecting part of the tip of a needle knife enabled small and sharp marking, easy and safe mucosal incision and submucosal dissection. Emitting a jet of water from the tip of a sheath enables lavage of the viewing field, identification of the bleeding points and submucosal local injection without replacement of devices, which led to very efficient treatment. FlushKnife can be considered to be one of the useful operative instruments for ESD.

Endoscopic Submucosal Dissection Using New Devices (Flushknife) for Gastric Tumors

Introduction: The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of lesions, which were conventionally difficult. However, ESD is associated with a high level of technical difficulty and a high incidence of complications. In order to ESD more easily, safely, and efficiently, we invented water jet short needle knives (FlushKnife) having a tip portion with five projection length of 1,1.5, 2, 2.5 and 3 mm that can emit a jet of water from the tip of a sheath. Aims & Methods: We treated 162 lesions in 154 patients (102 intramucosal cancers, 23 submucosal cancers, and 37 adenomas) with ESD using FlushKnife between March and November 2005.

Endoscopic Submucosal Dissection for Large Colorectal Tumors

Endoscopic Submucosal Dissection for Large Colorectal Tumors Takashi Toyonaga, Eisei Nishino, Akira Hayashibe, Takashi Hirooka Background: The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of large colorectal tumors. However, ESD is associated with a high level of technical difficulty and a high incidence of complications. In our department, ESD has been applied to lesions larger than 20 mm in diameter since June 2002, and we have obtained good results by choosing therapeutic instruments according to the situation. Methods: We studied 102 colorectal lesions in 98 patients (62 adenomas, 29 intramucosal cancers and 11 submucosal cancers) undergoing ESD in our department between June 2002 and November 2004. The locations: 13 lesions in the cecum, 28 in the ascending colon, 11 in the transverse, 4 in the descending, 15 in the sigmoid, and 31 in the rectum. Resection method: Erbotome ICC 200 was used for a electro-surgical unit, and a 4-mm length attachment was put on the endoscope tip in order to treat as below. Fourfold diluted hyaluronate sodium was locally injected into the submucosal layers, and the marginal mucosa around the lesions were incised with a Flex knife. Then, a Flex knife was mainly used, but a precutting knife for fibrotic targets and a Hook knife for the situations that muscle layers were located in front were appropriately combined in order to dissect the submucosal layers. When it was difficult to maintain the good endoscopic view, a small caliber-tip transparent hood was used. Results: The diameter of tumors: 13-104 mm (median 28 mm), the diameter of resection specimens: 20-114 mm (median 38 mm), En-bloc and complete resection rate: 96.1% (98/102). With 4 lesions (3.9%) for which en-bloc resection could not be performed, complete fractionated resection was performed after mucosal incision of the entire circumference. Operation time: 16-248 min. (median 42 min). Complications: intra-operative perforation 2.0% (2/102), delayed perforation 1.0% (1/102). The intra-operative perforations were shaped like a pinhole and were conservatively cured by clipping. The delayed perforation required surgery, and it was considered from the resection specimen that the perforation was due to necrosis of the muscle layer by electric current. Intra-operative bleeding with difficulty in hemostasis and post-operative bleeding requiring hemostasis were not observed. Conclusions: We obtained good results in resection by using ESD for large colorectal tumors. Combined therapeutic instruments were useful.