Endoscopic Submucosal Dissection Research Articles

Synchronous cancers of the stomach and esophagus in a patient with autoimmune gastritis and pernicious anemia: a case report and review of the literature.

Type-A gastritis/autoimmune gastritis (AIG) has gained renewed attention due to declining Helicobacter pylori infection rates and increasing eradication. AIG is associated with pernicious anemia (PA) and is prone to complicate various tumors, such as gastric cancer and neuroendocrine tumors. This report describes a case of AIG with PA in which gastric and esophageal cancers arose simultaneously. An 86-year-old woman had been diagnosed with PA and AIG 9 years earlier. As routine blood tests revealed high levels of carcinoembryonic antigen, she underwent esophagogastroduodenoscopy, which revealed a type 0-IIa lesion in the middle part of the stomach and a type 0-IIa + IIb lesion in the lower esophagus. Endoscopic submucosal dissection was performed on both lesions, since neither distant nor lymph node metastases were identified. Histological examination showed gastric tubular adenocarcinoma and esophageal squamous cell carcinoma. Immunohistology revealed that cells from neither cancer expressed gastrin, gastrin receptor, or p53. Whole-exome sequencing showed 8 gene mutations in the esophageal cancer and 6 mutations in 5 genes in the gastric cancer. The reason for the lack of p53 immunostaining was that TP53 was mutated in these cancers, although TP53 mutations differed. Thus, TP53 mutations may not be detected by immunostaining alone. When treating patients with AIG/PA, clinicians must be aware of the possibility of esophageal cancer coexisting with gastric cancer.

Association of local steroid injection as a risk factor for electrocoagulation syndrome after esophageal endoscopic submucosal dissection.

Postendoscopic submucosal dissection electrocoagulation syndrome (PEECS) is commonly observed after performing endoscopic submucosal dissection (ESD) for esophageal neoplasia. However, data on the incidence and risk factors for PEECS in the esophagus are lacking due to an unclear definition of PEECS and varied clinical settings. Therefore, we aimed to determine the risk factors for PEECS in patients undergoing ESD for esophageal neoplasia. We retrospectively reviewed data of relevant clinical and endoscopy-specific parameters from 202 consecutive patients with esophageal neoplasias (139 carcinomas and 63 dysplasias) who underwent ESD under general anesthesia. Esophageal PEECS was defined by satisfying at least two of the following criteria: fever ≥ 37.8°C, leukocytosis ≥ 10,800/mm3, and localized chest pain ≥ 5/10 points as assessed on a numeric rating scale within 24h after ESD. Significant factors associated with PEECS were determined by regression analysis. PEECS was recorded in 98 of 202 (48.5%) patients. Patients with PEECS exhibited a larger tumor size (25.0 vs. 17.0mm, P = 0.002), longer procedure (40.0 vs. 29.5min, P = 0.021) and hemostasis times (5.0 vs. 3.5min, P = 0.004), required greater submucosal injection volume (60.0mL vs. 50.0mL, P = 0.030), and had a lower rate of local steroid injection (4.1% vs. 12.5%, P = 0.029) than those without PEECS. Multivariate regression analysis revealed tumor size ≥ 17mm (P = 0.047), procedure time ≥ 33min (P = 0.027), and hemostasis time ≥ 5min (P = 0.007) as risk factors for PEECS. In addition, local steroid injection was a significant negatively associated factor (P = 0.001). Patients with a large tumor, prolonged procedure and hemostasis times are at a high risk of PEECS occurrence. Further, local steroid injection is a negatively associated factor.

Comparison of high-flow nasal cannula and conventional nasal cannula during deep sedation for endoscopic submucosal dissection: a randomized controlled trial.

Adequate oxygenation and airway management during deep sedation can be challenging. We investigated the effect of high-flow nasal cannula (group HF) and conventional nasal cannula (group CO) during sedation for endoscopic submucosal dissection (ESD). Patients undergoing ESD with deep sedation were enrolled. The primary outcome was difference in lowest oxygen saturation (SpO2) between the groups. Incidence of hypoxia (SpO2 < 90%), patients with SpO2 < 95%, hypercapnia, and airway interventions; operator satisfaction; and adverse events were recorded. Thirty-two patients in each group completed the study. The mean of minimum SpO2 values was significantly higher in group HF than in group CO (96.8% ± 4.2% vs. 93.3% ± 5.3%, p = 0.005). The incidence of hypoxia was comparable between the groups (4 [12.5%] vs. 6 [18.8%], p = 0.491); however, patients with SpO2 < 95% were significantly less in group HF (5 [15.6%] vs. 18 [56.3%], p = 0.003). Incidence of hypercapnia was higher in group HF than in group CO (14 [46.7%] vs. 5 [16.7%], p = 0.013). Airway rescue interventions were significantly less common in group HF. Satisfaction of operators and post-procedural complications were comparable between the two groups. In multivariable analysis, group CO and higher body mass index were risk factors for airway managements (odds ratio [95% confidence interval]: 6.204 [1.784-21.575], p = 0.004; 1.337 [1.043-1.715], p = 0.022, respectively). Compared to conventional nasal cannula, high-flow nasal cannula maintained higher minimum SpO2 value during deep sedation with propofol-remifentanil for ESD. Clinical Trial Registry of the Republic of Korea (KCT0006618, https://cris.nih.go.kr ; registered September 29, 2021; principal investigator: Ji Won Choi).

Outcomes of endoscopic submucosal dissection versus esophagectomy for poorly differentiated superficial esophageal squamous cell carcinoma: A 10-year cohort study

BackgroundsThe efficacy of endoscopic submucosal dissection (ESD) to treat poorly differentiated superficial esophageal squamous cell carcinoma (SESCC) is unclear. AimsTo exploring the efficacy and prognosis of ESD treatment poorly differentiated SESCC compared with esophagectomy. MethodsA retrospective cohort study was conducted, the data of poorly differentiated SESCC patients who received ESD or esophagectomy from Jan 2011 to Jan 2021 were analyzed. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and procedure-related variables were compared between ESD and esophagectomy group. Results95 patients underwent ESD, while 86 underwent esophagectomy. No significant differences were found between the two groups in OS (P = 0.587), DSS (P = 0.172), and RFS (P = 0.111). Oncologic outcomes were also similar between the two groups in propensity score–matched analysis. For T1a ESCC, the rates of R0 resection, LVI or nodal metastasis and additional therapy were similar between ESD and esophagectomy groups. But for T1b ESCC, the rates of positive resection margin and additional therapy were significantly higher in ESD group than those in esophagectomy group. ConclusionsESD is a minimally invasive procedure that has comparable oncologic outcomes with esophagectomy for treatment poorly differentiated T1a ESCC. However, ESD is not suitable for poorly differentiated T1b ESCC, additional surgery or radiochemotherapy should be required.

A multicenter, retrospective study of a through-the-needle injection–capable electrosurgical knife for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a technically challenging resection technique for en bloc removal of dysplastic and early cancerous GI lesions. We conducted a single-arm retrospective study evaluating the safety and efficacy of a new through-the-needle injection-capable electrosurgical knife used in upper and lower ESD procedures performed at 6 U.S. academic centers. Data were retrospectively collected on consecutive cases in which the new ESD knife was used. The primary efficacy endpoint was successful ESD (en bloc resection with negative margins). Secondary efficacy endpoints included en bloc resection rate, curative resection rate, median ESD time, and median dissection speed. The safety endpoint was device- or procedure-related serious adverse events. ESD procedures of 581 lesions in 579 patients were reviewed, including 187 (32.2%) upper GI and 394 (67.8%) lower GI lesions. Prior treatment was reported in 283 (48.9%) patients. Successful ESD was achieved in 477 (82.1% of 581) lesions-lower for patients with versus without submucosal fibrosis (73.6% vs 87.0%, respectively; P< .001) but similar for those with versus without previous treatment (81.7% vs 82.3%, respectively; P= .848). A total of 443 (76.2% of 581) lesions met criteria for curative resection. Median ESD time was 1.0 (range, 0.1-4.5) hour. Median dissection speed was 17.1 (interquartile range, 5.3-29.8) cm2/h. Related serious adverse events were reported in 15 (2.6%) patients, including delayed hemorrhage (1.9%), perforation (0.5%), or postpolypectomy syndrome (0.2%). A newly developed through-the-needle injection-capable ESD knife showed a good success rate and excellent safety at U.S. (Clinical trial registration number: NCT04580940.).

Comparative Efficacy and Acceptability of Endoscopic Methods for Rectal Neuroendocrine Neoplasms with Low Malignant Potential: A Network Meta-analysis.

Although endoscopic resection is an effective treatment of rectal neuroendocrine neoplasms (R-NENs) with low malignant potential, there is no consensus on the most recommended endoscopic method. This study aimed to assess the efficacy and acceptability of different endoscopic treatments for R-NENs with low malignant potential. We searched databases for studies on treatments of R-NENs using endoscopic resection. These studies comprised techniques such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), modified endoscopic mucosal resection (EMRM), modified endoscopic submucosal dissection (ESDM), and transanal endoscopic microsurgery (TEM). The primary outcomes assessed were histological complete resection (HCR). Overall, 38 retrospective studies (3040 R-NENs) were identified. Endoscopic mucosal resection with a cap (EMRC), endoscopic mucosal resection with ligation (EMRL), ESD, ESDM, and TEM demonstrated higher resectability than did EMR in achieving HCR. Endoscopic mucosal resection, EMRC, EMRL, EMRP, EMRD, and EMRU required shorter operation times than did ESD. Endoscopic mucosal resection, EMRC, ESDM, and TEM incurred lower risks than did ESD. Regarding R-NENs <20 mm with low malignant potential, ESD could be used as the primary treatment. However, TEM may be more effective if supported by economic conditions and hospital facility. With respect to R-NENs <16 mm with low malignant potential, EMRL could be used as the primary treatment. In regard to R-NENs <10 mm with low malignant potential, EMRL, EMRC, and ESD could be used as the primary treatment. However, EMRL and EMRC might be better when operational difficulties and economic conditions were considered.

Long-term prognosis and DNA damage status after oral mucosal epithelial cell sheet transplantation following esophageal endoscopic submucosal dissection for squamous cell carcinoma: A case series

Autologous oral mucosal epithelial cell sheet (AOMECS) transplantation has recently been applied in human patients to prevent postprocedural stenosis following endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma. However, the long-term safety of AOMECS transplantation remains unclear. We evaluated the long-term outcomes of 10 patients who participated in a clinical trial of AOMECS transplantation after esophageal ESD. Additionally, we assessed the local DNA damage response in the esophageal epithelium using p53 binding protein 1 (53BP1) immunofluorescence in post-AOMECS biopsy specimens. The median follow-up period was 118.5 months (range: 46–130 months). Two patients developed primary esophageal cancer near the AOMECS site and successfully underwent additional ESD. One patient developed lymph node metastasis and underwent chemotherapy. None of the patients died from the original disease, although one patient died from unrelated causes. The rate of abnormal 53BP1 nuclear foci, indicative of increased genome instability, increased with the progression of neoplasia in patients post AOMECS. Our case series suggests that AOMECS transplantation provides an acceptable long-term prognosis and 53BP1 foci may serve as a useful marker for assessing DNA instability in the post-AOMECS esophageal epithelium.

Multi-region exome sequencing to determine the origin of esophageal spindle-cell squamous cell carcinoma.

4072 Background: Esophageal spindle-cell squamous cell carcinoma (ESS) is a rare biphasic neoplasm composed of carcinomatous and sarcomatous components. However, the genomic origin and gene signature of ESS remain unclear. Methods: A total of 24 patients diagnosed with ESS were enrolled from Shanghai Chest Hospital and underwent either radical resection (23/24) or endoscopic submucosal dissection (1/24). Laser-capture microdissection was employed to isolate cancerous and sarcomatous components from tumor and lymph node metastatic tissues. The cancerous components were subsequently microdissected based on morphology. Whole exome sequencing (WES) was conducted on both tumor tissues and paired white cell samples to analyze genomic profiles. Results: The tumor tissue samples of carcinomatous and sarcomatous components showed high mutational commonality. With the same top high-frequency mutant genes, mutation signatures, and tumor mutation burden, paired samples shared a median of 25.5% mutation sites. Focal gains were found on chromosomes 3q29, 5p15.33, and 11q13.3. Altered genes were mainly enriched in the RTK-RAS signaling pathway. Phylogenetic trees showed a monoclonal origin of ESS. The most frequently mutated oncogene in the trunk was TP53, followed by NFE2L2, KMT2D, and MUC16. It showed a significant association of CDC27, LRP2, APC, and SNAPC4 mutations with poor prognosis in ESS patients. Our data highlight the monoclonal origin of ESS with TP53 as a potent driver oncogene, suggesting new targeted therapies and immunotherapies as treatment options. Conclusions: In conclusion, our results regarding to the mutation characteristics of microdissected samples substantiate the monoclonal origin of both the carcinomatous and sarcomatous components of ESS.

Mucin phenotype and microvessels in early gastic cancer: Magnifying endoscopy with narrow band imaging

BackgroundsIn order to detect early gastric cancer (EGC), this research sought to assess the diagnostic utility of magnifying endoscopy (ME) as well as the significance of mucin phenotype and microvessel features. Methods402 individuals with an EGC diagnosis underwent endoscopic submucosal dissection (ESD) at the Department of ME between 2012 and 2020. After adjusting for image distortion, high-magnification endoscopic pictures were taken and examined to find microvessels in the area of interest. The microvessel density was measured as counts per square millimeter (counts/mm2) after segmentation, and the vascular bed's size was computed as a percentage of the area of interest. To identify certain properties of the microvessels, such as end-points, crossing points, branching sites, and connection points, further processing was done using skeletonized pixels. ResultsAccording to the research, undifferentiated tumors often lacked the MS pattern and showed an oval and tubular microsurface (MS) pattern, but differentiated EGC tumors usually lacked the MS pattern and presented a corkscrew MV pattern. Submucosal invasion was shown to be more strongly associated with the destructive MS pattern in differentiated tumors as opposed to undifferentiated tumors. While lesions with a corkscrew MV pattern and an antrum or body MS pattern revealed greater MUC5AC expression, lesions with a loop MV pattern indicated higher MUC2 expression. Furthermore, CD10 expression was higher in lesions with a papillary pattern and an antrum or body MS pattern. ConclusionThese results imply that evaluating mucin phenotype and microvessel features in conjunction with magnifying endoscopy (ME) may be a useful diagnostic strategy for early gastric cancer (EGC) detection. Nevertheless, further investigation is required to confirm these findings and identify the best course of action for EGC diagnosis.

436P Robotic endoscopic submucosal dissection for early-stage gastric neoplasia: A comprehensive review and meta-analysis

436P Robotic endoscopic submucosal dissection for early-stage gastric neoplasia: A comprehensive review and meta-analysis

Endoscopic Submucosal Dissection of a Large Rectal Lesion by Using a Novel Traction Device to Facilitate Traction Adjustments

Endoscopic Submucosal Dissection of a Large Rectal Lesion by Using a Novel Traction Device to Facilitate Traction Adjustments

Dexmedetomidine-pethidine combination for sedation during esophageal endoscopic submucosal dissection

Dexmedetomidine-pethidine combination for sedation during esophageal endoscopic submucosal dissection

Optimizing a self-solidifying hydrogel as an endoscopically deliverable hydrogel coating system: a proof-of-concept study on porcine endoscopic submucosal dissection-induced ulcers

Endoscopic submucosal dissection (ESD) benefits patients in the early stages of cancer, but it poses various risks of complication. Strategies involving the application of clinically approved products to cover ulcers caused by ESD can reduce these complications, but the fixed nature of their properties limit the understanding of their effects on ulcer healing. This study was focused on Tetra–PEG gel, an innovative hydrogel with controllable physical properties made from a sulfhydryl–maleimide pair. The use of biocompatible polyethylene glycol (PEG) in Tetra–PEG gel may allow for its application as a biomaterial. The aims of our study were to identify the characteristics of a self-solidifying hydrogel for endoscopic application and to develop a new ulcer coating agent for post-ESD treatment. We developed a specialized double-lumen catheter and determined the optimal application conditions of the hydrogel. We examined the hydrodynamic properties of the gelling solutions and elucidated the pressure drop that occurred during device operation. Finally, by considering previous experimental results, we successfully applied the hydrogel to post-ESD ulcers in porcine stomachs. We believed that by further optimizing hydrogels with effectively controlled properties and by continuing to investigate them through animal experiments, we could expand our understanding of the relationships among material and ulcer healing properties and apply this knowledge to clinical applications.

Electrosurgery in Gastrointestinal Endoscopy: Bench to Bedside

AbstractElectrosurgical generator units (ESUs) are instrumental in modern therapeutic gastrointestinal (GI) endoscopy, converting household alternating current into high-frequency current to generate thermal energy within tissues. This review elucidates the essentials of electrosurgery, exploring the thermal effects on tissue, current resistance, voltage, current density, duty cycle, crest factor, and the distinctions between monopolar and bipolar circuitry. The concept of duty cycle, the proportion of time electrical current is delivered, and crest factor, the ratio of peak to root mean square voltage, are essential while comparing differently named modes across various commercially available ESUs. This article discusses the practical applications of electrosurgery in therapeutic GI endoscopy procedures, including endoscopic sphincterotomy, polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and peroral endoscopic myotomy. It outlines recommended modes and settings for ESUs across various procedures, emphasizing the balance between cutting and coagulation to achieve optimal outcomes while minimizing adverse effects. The review further addresses special considerations for the use of grounding pads and the management of patients with implanted cardiac devices during electrosurgical procedures. This article concludes with a call for a deeper understanding of electrosurgical principles and their application in GI endoscopy to ensure patient safety and procedural success, backed by references to relevant literature and detailed tables summarizing electrosurgical modes and settings for various therapeutic interventions.

New traction technique in endoscopic submucosal dissection for large colorectal lesions: roll-uptechnique

New traction technique in endoscopic submucosal dissection for large colorectal lesions: roll-uptechnique

Clinical outcomes of colorectal neoplasm with positive resection margin after endoscopic submucosal dissection

A positive resection margin after colorectal endoscopic submucosal dissection (ESD) is associated with an increased risk of recurrence. We aimed to identify the clinical significance of positive resection margins in colorectal neoplasms after ESD. We reviewed 632 patients who had en bloc colorectal ESD at two hospitals between 2015 and 2020. The recurrence rates and presence of residual tumor after surgery were evaluated. The rate of additional surgery after ESD and recurrence rate were significantly higher in patients with incomplete resection (n = 75) compared to patients with complete resection (n = 557). When focusing solely on non-invasive lesions, no significant differences in recurrence rates were observed between the groups with complete and incomplete resection (0.2% vs. 1.9%, p = 0.057). Among 84 patients with submucosal invasive carcinoma, 39 patients underwent additional surgery due to non-curative resection. Positive vertical margin and lymphovascular invasion were associated with residual tumor. Lymphovascular invasion was associated with lymph node metastasis. However, no residual tumor nor lymph node metastases were found in patients with only one unfavorable histological factor. In conclusion, a positive resection margin in non-invasive colorectal lesions, did not significantly impact the recurrence rate. Also, in T1 colorectal cancer with a positive vertical resection margin, salvage surgery can be considered in selected patients with additional risk factors.

Endoscopic submucosal dissection using the tunneling method for early gastric cancer occupying the entire fornix.

Endoscopic submucosal dissection using the tunneling method for early gastric cancer occupying the entire fornix.

Combination of a permanent slow flow managed by the nurse and a rapid flow for bleeding management controlled by the doctor in underwater endoscopic submucosal dissection.

Combination of a permanent slow flow managed by the nurse and a rapid flow for bleeding management controlled by the doctor in underwater endoscopic submucosal dissection.

Large defect closure using a helix tacking system and endoclips after endoscopic submucosal dissection of two adjacent colonic lesions.

Large defect closure using a helix tacking system and endoclips after endoscopic submucosal dissection of two adjacent colonic lesions.

Innovative endoscopic combination surgery for endoscopic submucosal dissection using two thin therapeutic endoscopes.

Innovative endoscopic combination surgery for endoscopic submucosal dissection using two thin therapeutic endoscopes.