Mucosal Endoscopic Dissection Research Articles

前胸壁皮弁で再建した下咽頭部分切除例

Endoscopic examination, including narrow-band imaging (NBI), is being increasingly used to detect early hypopharygeal cancer. Because these high-risk cases have already often undergone radiotherapy for esophageal cancer, early hypopharygeal cancer is a good indication for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Slightly larger tumors, however, require partial hypopharyngotomy preserving the larynx. Since reconstruction with a free flap may be highly invasive, we reported using an anterior chest skin flap as a useful alternative in pharyngeal reconstruction.

Is there a Robust Predictor for the Remnant Gastric Cancer After Gastrectomy for Synchronous Multiple Gastric Cancer? Reply

To the Editor, We acknowledge the constructive comment by Hottenrott et al. to our report concerning the robust predictors of remnant gastric cancer after gastrectomy for synchronous multiple gastric cancers. He suggested that although our findings were determined by using a large number of cases, there are several weakness: (1) our study, which is based on a retrospective analysis with absolute number of incidence of remnant gastric cancer, is small and the combination of multiple lesion with undifferentiated type as an initial lesion is even more rare; (2) our study did not show a relationship between timing of development of remnant gastric cancer and tumor-free distance; (3) our study did not show the genetic background of the patients, particularly the status of CDH1, which is an important marker of remnant gastric cancer. The incidence of remnant gastric cancer is reported to be approximately 1% and the development of remnant gastric cancer after gastrectomy for synchronous multiple gastric cancer is an even rarer event; thus, it is quite challenging to establish the solid risk factors in a prospective manner [1]. Additionally, the situation could be complicated because there is multiple definitions of ‘‘remnant gastric cancer’’ in the world. We examined the relationship between the timing of the development of remnant gastric cancer and tumor-free distance at initial surgery and found that there was no significant correlation (r = 0.445, P = 0.375; two-tail) nor did it show the trend that close surgical margin is potentially associated with early development of remnant gastric cancer. Regarding the issue of molecular paradigm in the development of remnant gastric cancer, exploration of the predictor in the aspect of genetic background is fascinating. It is possible that status of CDH1 is one of the most important predictors for the development of remnant gastric cancer [2]. However, considering that treatment with endoscopic mucosal dissection (ESD) has been widely accepted both for primary gastric cancer and remnant gastric cancer [3], total gastrectomy may be excessive treatment for patients with early gastric cancer who are candidates for ESD. Thus, we believe that the status of single genetic marker is not enough for the consideration of initial total gastrectomy as the prevention purpose for remnant gastric cancer in patients with gastric cancer who are candidates for partial gastrectomy.

Endoscopic mucosal resection and endoscopic submucosal dissection in the West – too many concerns and caveats?

Endoscopic mucosal resection and endoscopic submucosal dissection in the West – too many concerns and caveats?

Toluidinblau in der gastrointestinalen Endoskopie

For decades, methylene blue has been used in gastrointestinal endoscopy as an absorbing dye, it was, however, not approved for that purpose and has now been withdrawn from the market. A possible substitute is toluidine blue, an acidophilic, metachromatic dye that selectively stains cell nuclei; accordingly, since 2007, toluidine blue has been approved as a topical diagnostic agent in chromoendoscopy. Cells with increased DNA synthesis are stained more intensively so that not only malignant cells but also erosions, ulcerations and inflammatory areas are stained with toluidine blue because of the increased reparative cellular processes. Up to now, absolutely no studies have been carried out with regard to the effectiveness of toluidine blue in gastrointestinal endoscopy. We report on a consecutive series of 364 endoscopic applications of toluidine made on the basis of various indications. Besides the known indications (e. g., chromoendoscopy in case of Barrett's oesophagus), we mostly used toluidine blue, diluted in hydroxyethylstarch (HAES), for submucosal injections of flat adenomas prior to endoscopic mucosal resection or endoscopic submucosal dissection, in order to precisely determine the extension of visible lesions. Local and systemic adverse reactions have not been observed. A demarcation of the lesions can be made as effectively as with methylene blue.

Salvage photodynamic therapy for extended carcinoma in situ of the oesophagus after subtotal oesophagectomy: 2 years follow up

The incidence of oesophageal cancer continuously increases and 400 000 new cases/year are diagnosed worldwide. Total oesophagectomy is recommended when multifocal disease, especially in case of Barrett's oesophagus [1]. However, selected cases may benefit from subtotal oesophagectomy, with 5-year survival rates ranging from 20% to 50% [1] G. Decker, W. Coosemans and P. De Leyn et al., Minimally invasive oesophagectomy for cancer, Eur J Cardiothorac Surg 35 (2009), pp. 13–20.[1]. Local recurrence after subtotal oesophagectomy is relatively high (30–40%) and regular endoscopic surveillance is mandatory. Early stage lesions are eligible for endoscopic minimally invasive surgery such as endoscopic mucosal resection or dissection (EMR, EMD), argon plasma photocoagulation, radiofrequency ablation or photodynamic therapy (PDT). Photodynamic therapy is now commonly applied to eradicate dysplasia and Barrett's oesophagus but can also achieve destruction of squamous cell carcinoma. In the present paper, we report a case of multifocal high grade dysplasia, in a patient with prior subtotal oesophagectomy, treated with PDT.

Endoscopic therapy using an endoscopic variceal ligation for minute cancer of the esophagogastric junction complicated with esophageal varices: a case report

IntroductionStandard endoscopic mucosal resection or endoscopic submucosal dissection is a procedure for patients with minute cancers, complicated with esophageal varices that puts them at high risk of bleeding.Case presentationWe present the case of a 77-year-old Japanese man with alcoholic cirrhosis who underwent a routine endoscopy examination as a screening procedure for esophageal varices and was incidentally diagnosed as having minute cancer of the esophagogastric junction with esophageal varices. Endoscopic ultrasonography findings suggested that the minute cancer was a non-invasive carcinoma (carcinoma in situ) and a 2 mm in diameter blood vessel, feeding the esophageal varices, pierced the lesion. Following the examination, we carried out endoscopic treatment of the minute cancer and esophageal varices. Endoscopic variceal ligation was performed using a pneumo-activated device (Sumitomo Bakelite, Tokyo, Japan). Two years after the treatment, during the follow-up endoscopic examination on the patient, recurrence of carcinoma was not detected endoscopically or histologically.ConclusionEndoscopic therapy using an endoscopic variceal ligation device for minute cancer of the esophagogastric junction, complicated with esophageal varices, may be an acceptable and easily applicable method.

Tissue apposition system: new technology to minimize surgery for endoscopically unresectable colonic polyps

This is the first clinical series using the Tissue Apposition System (TAS) device in a feasibility study of polypectomy as an alternative to laparoscopic colectomy (LC) for endoscopically unresectable polyps. TAS is a novel T-tag system for endoscopic placement of sutures, facilitating closure of larger defects from advanced endoluminal or transluminal endoscopic procedures. Such novel instrumentation may reduce risk and accelerate recovery. After institutional review board approval, patients with endoscopically unresectable polyps who would otherwise require LC were enrolled. The polyp site was visualized by colonoscopy and resected with laparoscopic assistance, using endoscopic mucosal resection (EMR) or submucosal dissection. After confirming benign disease by frozen section, the polypectomy site was closed by TAS under laparoscopic observation to avoid injury to surrounding structures. Follow-up colonoscopy was performed at 3 months. Seven patients were recruited (5 men; mean age, 66 years). Polyps were from 20 to 50 (mean, 30) mm in diameter; six were in the right colon, and three were on the mesenteric border of the bowel. All final pathology was benign. Mean EMR time was 29 min, mean time taken for TAS was 37 min, and mean total operative time was 199 min. Two TAS procedures required conversion to LC (one unresectable polyp and one device failure). Five TAS procedures were completed, with a mean hospital stay of 1.2 days, and no complications. Follow-up colonoscopy revealed healing without polyp recurrence in any case. One patient (initial 5-cm sigmoid polyp) developed a very mild clinically asymptomatic stricture in the sigmoid colon. This initial human experience demonstrates that TAS can be used safely in the colon under laparoscopic control. TAS permits safe closure of defects after endoscopic polypectomy of selected and otherwise unresectable polyps. Such technology may potentially avoid the need for LC and permit rapid recovery with short hospital stay.

M1412: Endoscopic Inanimate Biological Simulators for Training in Endoscopic Mucosal Dissection

Simulators have been widely used as a training method; they reproduce real, difficult and rare situations. In endoscopy, they allow training, skill development, standardization of techniques and the performance of a greater number of risk-free procedures. The EASIE (Erlangen Active Simulator for Interventional Endoscopy) biological simulator has been widely accepted. In this model the upper gastrointestinal (GI) and biliopancreatic tract of slaughter house pigs is placed inside a human-like mannequin. Studies have shown that it is plausible to reproduce GI tract lesions in animal inanimate models for training purposes. Early gastric cancer is limited to the mucosa or submucosa regardless of lymph node status. Endoscopic resection is the standard treatment for early gastric cancer in Japan and its acceptance is increasing worldwide. Endoscopic submucosal dissection (ESD) allows en bloc resection of larger lesions, requires longer procedure time and has more complications than endoscopic mucosal resection (EMR).

Endoscopic removal of gastric ectopic pancreas: An initial experience with endoscopic submucosal dissection

To evaluate the therapeutic usefulness and safety of endoscopic resection in patients with gastric ectopic pancreas. A total of eight patients with ectopic pancreas were included. All of them underwent endoscopic ultrasonography before endoscopic resection. Endoscopic resection was performed by two methods: endoscopic mucosal resection (EMR) by the injection-and-cut technique or endoscopic mucosal dissection (ESD). We planned to perform EMR in all eight cases but EMR was successful in only four cases. In the other four cases, saline spread into surrounding normal tissues and the lesions became flattened, which made it impossible to remove them by EMR. In those four cases, we performed ESD and removed the lesions without any complications. If conventional EMR is difficult to remove gastric ectopic pancreas, ESD is a feasible alternative method for successful removal.

2．高齢者の早期胃癌を効果的に内視鏡治療するための適応

Endoscopic resection, including endoscopic mucosal dissection (ESD), has gained acceptance widely for early gastric cancer (EGC). However, after therapy, some elderly patients with non-curative resection do not undergo radical surgery, because elderly patients may have limited life expectancy or comorbid disease. The aim of this study is to verify if radical surgery after non-curative resection should be performed in the elderly patients as in young patients. This is a retrospective review of 432 elderly patients (over 75 years) who had undergone enodscopic resection for EGC at the National Cancer Center Hospital between January 1999 and December 2005. We compared the overall and disease-free survival rate between the curative resection group, non-curative resection with surgery group, and non-curative resection without surgery group. A significant difference in overall and disease-free survival was evident between the patients with curative resection and non-curative resection without surgery. In the patients with non-curative resection for ECG endoscopically, additional surgery is still necessary even in elderly patients.

ENDOSCOPIC SUBMUCOSAL DISSECTION IN THE UPPER GASTROINTESTINAL TRACT: PRESENT AND FUTURE VIEW OF EUROPE

In Western countries endoscopic mucosal resection (EMR) has been widely accepted for treatment of early Barrett;s neoplasia and flat or depressed colorectal adenomas. In contrast endoscopic submucosal dissection (ESD) is infrequently performed for several reasons. It seems to be difficult to overcome the learning curve of this difficult technique because of the low case volume of early gastric cancer. On the other hand ESD of esophageal or colorectal lesions is even more challenging and is considered to be inappropriate for learning. In addition the indication for esophageal or colorectal ESD is controversial in view of excellent results of the well established EMR technique which is less time-consuming and safer than ESD. A recent survey of leading Western endoscopy centers indicated the limited experience with ESD with a low number of cases for all potential indications. Only a few training courses have been established and the number of ongoing clinical studies is limited. Only 12 out of 340 published articles on "endoscopic mucosal dissection" were reported from Western countries. A better acceptance of ESD requires improvement of the technique to allow an easier, faster and safer approach. There is a strong demand for structured training courses and limitations of human cases to selected centers which participate in prospective trials. A close collaboration between Western and Asian centers is recommended for improvement of the ESD technique and its clinical application.

Endoscopic Mucosal Resection Versus Endoscopic Submucosal Dissection According to the Sizes and the Subtypes of Laterally Spreading Tumors

Endoscopic Mucosal Resection Versus Endoscopic Submucosal Dissection According to the Sizes and the Subtypes of Laterally Spreading Tumors

Usefulness of bispectral monitoring of conscious sedation during endoscopic mucosal dissection

To assess the usefulness of bispectral index (BIS) monitoring in order to carry out endoscopic submucosal dissection (ESD) safely and with patients' satisfaction. Three hundred sixty-six patients with an early-stage neoplasm of the digestive tract were enrolled. The BIS monitor (A-1050: Aspect medical systems/NIHON KOHDEN, Tokyo, Japan) was used. The appropriate sedative condition was set at 55 to 75 BIS levels (BIS value) during the endoscopic procedures. Among 366 cases, 13 were accompanied by adverse events during and/or after ESD. All episodes occurred in cases with BIS value between 56 and 65. Hypotension was observed in four cases, and bradycardia in six. Respiratory distress was observed in two cases with chronic pulmonary obstructive disease. All patients with adverse events were able to leave the hospital without extension of the hospitalization. BIS monitoring is useful to safely perform ESD. A BIS value of 70 to 75 is suitable for ESD.

Prospective Randomized Comparison Between EMR and ESD for Endoscopic Removal of Superficial Esophageal Cancer

Various endoscopic methods have been shown successful in removing esophageal superficial tumors. Endoscopic mucosal resection is mainly performed by cap (EMR-C) or band ligation. Endoscopic mucosal dissection (ESD) has been developed in Japan to remove large lesions avoiding local recurrence and providing en bloc specimens for adequate pathological evaluation of lateral and deep margins. The aim of our study was to compare the safety, cost and efficacy (R0 resection and free deep and lateral margins) of esophageal EMR-C and ESD.

Clinical outcomes of endoscopic oblique aspiration mucosectomy for superficial esophageal cancer

EMR is now a widely accepted option for the treatment for superficial esophageal cancer (SEC). However, studies of medium-term to long-term outcomes are scarce. To evaluate outcomes in patients with SEC who are undergoing medium-term to long-term follow-up after endoscopic oblique aspiration mucosectomy (EOAM). A single-center retrospective study. Kitasato University East Hospital, Sagamihara, Kanagawa, Japan. From November 1999 to October 2005, 85 patients with SEC underwent EOAM. All tumors were macroscopically classified as the superficial type on the basis of preoperative endoscopic and EUS findings. Patients were followed-up, with an endoscopy every 6 months. Therapeutic efficacy, complications, and follow-up results. The rate of complete resection was 82.5% (70/85). In patients who underwent an incomplete resection, argon plasma coagulation and heat probe coagulation were, in addition, performed. The median longest diameter of the resected specimens was 25 mm. The median time required for a resection was 27 minutes. There was no perforation. Bleeding after an EOAM occurred in 1 patient (1.2%). Esophageal stenosis developed in 8 patients (9.4%). All strictures were managed by endoscopic balloon dilation, and symptoms improved. The median follow-up period after EMR was 36 months (range 6-72 months). Local recurrence occurred in 5 patients (5.9%); the nonrecurrence rate was 96.4% at 1 year, 95.0% at 2 years, and 93.4% at 3 years. As additional treatment, argon plasma coagulation was performed in 4 patients, and endoscopic mucosal dissection was conducted in 1 patient. EOAM is a safe, easy, and effective procedure for the treatment of SEC that can be completed within a short time. The rate of local recurrence is low on medium-term to long-term follow-up.

Improved Chromoendoscopy Effectively Defines Gastric Neoplasia Margins

Early gastric malignancies and premalignant neoplasia have been treated successfully with endoscopic mucosal resection or dissection, but complete removal requires accurate identification of the margins. In East Asia, where early gastric malignancy is more commonly detected, chromoendoscopy with indigo carmine dye has been used to define lesion margins prior to endoscopic therapy. Investigators in Japan compared the efficacy of indigo carmine dye, acetic acid, or …

Epstein-Barr Virus (EBV) 関連胃癌手術7年後に発生したEBV関連残胃癌の1例

A 52-year-old man undergoing distal gastrectomy for gastric cancer in July 1998 was found to have a 0-IIa type gastric tumor near EC junction in January 2005. Histological examination showed the tumor was moderately differentiated adenocarcinoma. As the tumor was diagnosed as mucosal cancer, endoscopic mucosal dissection was performed. But pathological findings showed the depth of cancer cell invasion into deep submucosal layer. Then total resection of remnant stomach was performed. Both tumors were diagnosed as EBV-associated carcinoma. It is speculated that the mucosa changing after initial operation would give risk to a new occurrence of EBV-associated remnant gastric carcinoma. And then follow up after operation is important. Although some cases of EBV-associated remnant gastric carcinoma is found for short period after the primary surgery, our case second primary cancer was found 7 year after primary surgery. Long term follow-up by Endoscopy seems to be important.

Considerations on endoscopic mucosal dissection in the treatment of gastrointestinal neoplasias: Endoscopic technique, results and treatment of complications

Considerations on endoscopic mucosal dissection in the treatment of gastrointestinal neoplasias: Endoscopic technique, results and treatment of complications

Endoscopic Mucosal Dissection (ESD) for Early Gastric Cancer (GC): A Prospective Study for Extension of the Indication of Endoscopic Mucosal Resection (EMR)

Background: Minimally invasive treatment such as EMR is widely noticed as a therapy for early GC. ESD is a promising EMR method which enables us to resect lesions en bloc as we like. Recently, in Japan, a guideline of treatment for GC shows some conditions of GC which are hardly associated with nodal metastasis. The aim of this study was to assess efficacy and safety of ESD against those lesions. Patients and Methods: We designed a prospective study in which ESD was applied in patients with differentiated-type GC up to 30 mm in diameter regardless of ulceration or above 30 mm without ulceration, but definite signs of submucosal invasion. According to final diagnosis after the ESD, GCs below, considered to have hardly metastasis, were followed up and otherwise were advised to be operated on additionally; differentiated-type mucosal GC above 30 mm in diameter without ulceration, and GC up to 30 mm with ulceration and/or minute submucosal invasion. The protocol was approved by the ethics committee of Osaka National Hospital, and consent to take part in the study was obtained from patients. Complete resection was defined if the lateral and basal margins were free of tumor pathologically. Followed-up endoscopic examinations are performed 1, 3, 6 months later, and then every six months. Results: Between Nov. 2001 and Nov. 2004, 180 lesions were enrolled. The average size of GC resected was 20 mm (range: 2-70 mm). Of 180 lesions, 144 (84%) were completely resected. Twenty-seven patients were recommended to have additional operation mainly because of massive submucosal invasion or lymphovascular involvement, and nodal metastasis was recognized in two of 12 patients who were actually operated on. Two of the remaining 153 patients recurred locally during follow-up period of median 19 mos (range: 3-36), and both were successfully treated by repeated ESD. No distant metastasis was noted. Perforation and bleeding were encountered in 9% and 8% of the patients respectively, which both happened more frequently in case of GC with ulceration (p < 0.05). No emergent surgery and no immediate mortality was noted. Conclusions: These results suggest that ESD is feasible for large mucosal GC without ulceration or for GC with ulceration and/or minute submucosal invasion up to 30 mm in diameter. However, to extend the indication of EMR for GC, correct pathological diagnosis obtained by en bloc resection is essential and the long-term prognosis should be investigated. Background: Minimally invasive treatment such as EMR is widely noticed as a therapy for early GC. ESD is a promising EMR method which enables us to resect lesions en bloc as we like. Recently, in Japan, a guideline of treatment for GC shows some conditions of GC which are hardly associated with nodal metastasis. The aim of this study was to assess efficacy and safety of ESD against those lesions. Patients and Methods: We designed a prospective study in which ESD was applied in patients with differentiated-type GC up to 30 mm in diameter regardless of ulceration or above 30 mm without ulceration, but definite signs of submucosal invasion. According to final diagnosis after the ESD, GCs below, considered to have hardly metastasis, were followed up and otherwise were advised to be operated on additionally; differentiated-type mucosal GC above 30 mm in diameter without ulceration, and GC up to 30 mm with ulceration and/or minute submucosal invasion. The protocol was approved by the ethics committee of Osaka National Hospital, and consent to take part in the study was obtained from patients. Complete resection was defined if the lateral and basal margins were free of tumor pathologically. Followed-up endoscopic examinations are performed 1, 3, 6 months later, and then every six months. Results: Between Nov. 2001 and Nov. 2004, 180 lesions were enrolled. The average size of GC resected was 20 mm (range: 2-70 mm). Of 180 lesions, 144 (84%) were completely resected. Twenty-seven patients were recommended to have additional operation mainly because of massive submucosal invasion or lymphovascular involvement, and nodal metastasis was recognized in two of 12 patients who were actually operated on. Two of the remaining 153 patients recurred locally during follow-up period of median 19 mos (range: 3-36), and both were successfully treated by repeated ESD. No distant metastasis was noted. Perforation and bleeding were encountered in 9% and 8% of the patients respectively, which both happened more frequently in case of GC with ulceration (p < 0.05). No emergent surgery and no immediate mortality was noted. Conclusions: These results suggest that ESD is feasible for large mucosal GC without ulceration or for GC with ulceration and/or minute submucosal invasion up to 30 mm in diameter. However, to extend the indication of EMR for GC, correct pathological diagnosis obtained by en bloc resection is essential and the long-term prognosis should be investigated.

IMPACT OF ULTRASONOGRAPHY ON DIAGNOSIS OF T1 ESOPHAGEAL CANCER AS A CANDIDATE FOR ENDOSCOPIC MUCOSAL RESECTION

To get the correction information to decide whether endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) should be performed, endoscopic examinations, including multiple modalities such as chromoendoscopy, magnifying endoscopy and ultrasonography, are routinely performed in one or two sessions of endoscopic examination. Ultrasonography provides a cross sectional view of the tumor, which is useful information in the decision between EMR or surgery. The final treatment strategy should be decided according to the histological analysis of the resected specimen.