Safety Of Endoscopic Submucosal Dissection Research Articles

Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection.

A new rendezvous-style surgical technique has been developed to ensure the safety of endoscopic submucosal dissection (ESD) for duodenal tumors. The new technique, called "laparoscopic-endoscopic cooperative surgery (LECS)," combines ESD with laparoscopic, reinforcing, seromuscular suturing. This case series report describes how three patients with a duodenal tumor were safely treated by LECS. ESD was performed by endoscopy, followed by closure of the mucosal defect using seromuscular suturing by laparoscopy. ESD was successfully completed in all patients. Endoscopic findings after suturing revealed that the mucosal defect was closed appropriately and tightly. None of the three patients experienced delayed perforation or stricture after LECS. LECS for extraction of duodenal tumors seems to be feasible and helps to ensure the safety of ESD in the duodenum.

Endoscopic submucosal dissection for colorectal lateral spreading tumors larger than 10 cm: Is it feasible?

Colorectal endoscopic submucosal dissection (ESD) was applied to lesions, such as giant colorectal lateral spreading tumors (LSTs) > 10 cm, by an expert ESD endoscopist despite several limitations, such as a relatively high perforation rate and high technical difficulty. To investigate the feasibility and safety of ESD for giant colorectal LSTs≥ 10 cm. Retrospective study. Tertiary-care center. A total of 163 patients underwent colorectal ESD between 2009 and 2014 by a single expert ESD endoscopist at Gangnam Severance Hospital, Seoul, Korea. Among them, 9 patients had giant colorectal LSTs≥ 10 cm. Review of records. Clinicopathologic factors and oncologic outcome associated with ESD between giant colorectal LSTs and others. Colorectal LSTs≥ 10 cm were classified as giant colorectal LSTs. Nine giant colorectal LST lesions were localized to the following regions: descending colon (n= 1), sigmoid colon (n= 1), and rectum (n= 7). The average maximal diameter of giant colorectal LSTs was 120.8mm, and the procedure time was 270.0 minutes. Two lesions were of the whole nodular type, and 7 were focal nodular lesions. The en bloc and curative resection rates for ESD for giant colorectal LSTs were 88.9% and 100%, respectively. The adverse event rate was 44.4%. No strictures, local recurrences, or distant metastases occurred over a mean follow-up period of 27.1 months. Retrospective, single-center study. ESD of giant colorectal LSTs appears to be a feasible and curative treatment, even though it is associated with a higher adverse event rate, higher degree of technical difficulty, and longer procedure time.

Clinical safety of endoscopic submucosal dissection compared with surgery in elderly patients with early gastric cancer: a propensity-matched analysis

Little is known about the clinical and oncologic outcomes of endoscopic submucosal dissection (ESD) compared with surgery in elderly patients with early gastric cancer (EGC). To evaluate the clinical and oncologic outcomes of ESD compared with surgery in elderly patients with EGC of an expanded indication. Retrospective study with propensity-matched analysis. University-affiliated tertiary-care hospital, Seoul, South Korea. A total of 518 patients 70 years of age or older with initial-onset EGC. ESD and surgery. Clinical outcomes, disease-free survival, and overall survival. In a propensity-matched analysis of 132 pairs, the length of hospital stay of the ESD group was shorter than that of the surgery group (median [interquartile range], 4 [3-4] vs 9 [7-11] days; P< .001). Intensive care unit admission occurred in the surgery group only (7 patients [5.3%]). Two surgery-related deaths occurred in the surgery group (1 splenic artery bleeding and 1 anastomosis site leakage). During follow-up, metachronous lesions developed more often in the ESD group than in the surgery group (12 vs 2 lesions, P= .004). All recurred lesions were successfully treated endoscopically except for 3 patients who refused additional treatment. Overall survival did not differ between the 2 groups (P= .280). Nonrandomized, retrospective study. ESD is a safe procedure in elderly patients with EGC. Although the risk of metachronous lesions is higher in patients who undergo ESD than in those who undergo surgery, overall survival did not differ between the patients who undergo ESD and surgery.

Sa1511 Clinical Safety of Endoscopic Submucosal Dissection Compared With Surgery in Elderly Patients With Early Gastric Cancer: a Propensity-Matched Analysis

Endoscopic submucosal dissection (ESD) is a feasible treatment option for elderly patients with early gastric cancer (EGC). However, little is known about the clinical and oncologic outcomes of ESD compared with surgery in elderly patients with EGC.

Endoscopic submucosal dissection for rectal carcinoid tumour using the Clutch Cutter.

To reduce the risk of complications related to endoscopic submucosal dissection (ESD) using knives, we developed the Clutch Cutter (CC), which can grasp and incise the target tissue similarly to biopsy techniques using an electrosurgical current. The aim of this study was to evaluate the efficacy and safety of ESD using the CC for removal of rectal carcinoid tumours. Between December 2009 and December 2011, we prospectively enrolled seven patients (seven lesions) on 7 different days. Patients were endoscopically diagnosed with rectal subepithelial lesions (upper rectum, n = 3; lower rectum, n = 4) within the level 3 layer and without lymph node involvement, with the diagnosis confirmed by preliminary endoscopy, endoscopic ultrasound and endoscopic biopsies. ESD using the CC was performed in all cases, and the therapeutic efficacy, safety and tumour recurrence were assessed. All lesions were treated easily and safely, and there were no inadvertent incisions. En bloc resection was obtained in all cases, and histologic tumour-free lateral/basal margins were obtained in six of the seven patients. No delayed haemorrhage, perforation or tumour recurrence occurred. ESD using the CC appears to be an easy, safe and technically efficient method for resecting rectal carcinoid tumour.

Efficacy and Safety of Endoscopic Submucosal Dissection for Superficial Squamous Esophageal Neoplasia: A Meta-Analysis

Although endoscopic submucosal dissection (ESD) has grown popular in resecting lesions in the stomach, the application of ESD to the esophagus has been limited by greater technical difficulty. An increasing number of series have recently reported the application of ESD to esophageal lesions. The aim of the present systemic review and meta-analysis was to evaluate the efficacy and safety of ESD for esophageal lesions. Comprehensive literature searches (1999-2012) were performed on studies that reported ESD for the removal of esophageal neoplasia. Primary outcome measures were pooled estimates of complete resection rate and en bloc resection rate. Secondary outcome measures were pooled estimates of complication rates. A total of 15 studies provided data on 776 ESD-treated lesions. The pooled estimate of complete resection rate was 89.4% (95% CI 86.2-91.9%). The pooled estimate of en bloc resection was 95.1% (95% CI 92.6-96.8%). The pooled estimates of complications of ESD such as bleeding, perforation, and stenosis were 2.1, 5.0, and 11.6%, respectively. ESD appeared to be an extremely effective technique to achieve complete resection of esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach.

Endoscopic Submucosal Dissection Versus Endoscopic Mucosal Resection for the Treatment of Early Esophageal Carcinoma: a Meta-analysis

Endoscopic submucosal dissection (ESD) was originally developed for en bloc resection of large, flat gastrointestinal lesions. Compared with endoscopic mucosal resection (EMR), ESD is considered to be more time consuming and have more complications for treatment of early esophageal carcinoma, such as bleeding, stenosis and perforation. The objective of this study was to compare the efficacy and safety of ESD and EMR for such lesions. We searched databases, such as PubMed, EMBASE, Cochrane Library and Science Citation Index updated to 2013 for related trials. In the meta-analysis, the main outcome measurements were the en bloc resection rate, the histologically resection rate and the local recurrence rate. We also compared the operation time and the incidences of procedure-related complications. Five trials were identified, and a total of 710 patients and 795 lesions were included. The en bloc and histologically complete resection rates were higher in the ESD group compared with the EMR group (odds ratio (OR) 27.3; 95% CI, 11.5-64.8; OR 18.4; 95% CI, 8.82-38.59). The local recurrence rate was lower in the ESD group (OR 0.13, 95 % CI 0.04-0.43). The meta-analysis also showed ESD was more time consuming, but did not increase the complication rate (P=0.76). The results implied that compared with EMR, ESD showed better en bloc and histologically resection rates, and lower local recurrence, without increasing the incidence of procedure-related complications in the treatment of early esophageal carcinoma.

Effectiveness and safety of endoscopic submucosal dissection for intraepithelial neoplasia of the esophagogastric junction

Background Endoscopic submucosal dissection of the esophagogastric junction is the most difficult gastric and esophageal dissection procedure. No reports of endoscopic submucosal dissection for Siewert type II carcinoma of the esophagogastric junction have compared the outcomes of endoscopic submucosal dissection for all three Siewert types of adenocarcinoma. This study aimed to evaluate the efficacy and safety of endoscopic submucosal dissection for intraepithelial neoplasia of the esophagogastric junction. Methods From October 2008 to June 2013, 73 patients underwent endoscopic submucosal dissection for intraepithelial neoplasia of the esophagogastric junction. The patients were prospectively evaluated regarding the executability of the technique, short-term results of the procedure, en bloc resection rate, curative resection rate, complications and additional treatment after endoscopic submucosal dissection, and follow-up outcomes. Results Sixty-eight of the 73 patients (93.2%) underwent en bloc resection; the mean maximum specimen diameter was 33.7 mm. Fifty-seven of 61 patients (93.4%) who underwent curative resection were successfully followed-up for 1.0 to 56.0 months (average, 24.1 months). Local recurrence developed in one patient with high-grade intraepithelial neoplasm. Twelve patients underwent noncurative resection, including lateral resection margin residues in three, vertical resection margin residues in one, signet ring cell carcinoma or undifferentiated adenocarcinoma in four, lymphatic or vessel invasion in one, vertical residual margin residues combined with signet ring cell carcinoma in one, and undifferentiated adenocarcinoma with lymphatic or vessel invasion in two. In the noncurative resection group, one patient was lost to follow-up, seven underwent additional surgery, and the remaining four were periodically followed up; none had local recurrence or distant metastases. The only complication was delayed bleeding in three patients, which was successfully controlled by conservative treatment or endoscopic therapy. Conclusions Endoscopic submucosal dissection is safe and effective for intraepithelial neoplasia of the esophagogastric junction. R0 en bloc resection is possible and can avoid the risk of local recurrence.

Comparison on the Long Term Outcome between Endoscopic Submucosal Dissection and Surgical Treatment for Undifferentiated Early Gastric Cancer

There are controversies on the efficacy and safety of endoscopic submucosal dissection (ESD) for un-differentiated early gastric cancer (EGC) despite the expansion of ESD indications. The aim of this study was to evaluate the long term outcome of ESD compared to that of surgical treatment in patients with undifferentiated EGC. A total of 76 patients who underwent ESD for undifferentiated EGC and 149 patients who met the ESD indication and received surgical treatment from January 2005 to December 2010 at Chonnam National University Hwasun Hospital were included. In the ESD group, en bloc resection and complete resection were achieved in 84.2% (64/76) and 76.3% (58/76) of patients, respectively. Among these patients, 58 (76.3%) met the ESD indication (indication group), and the remaining 18 (23.7%) did not meet the ESD indication (above indication group). Complete resection rates for indication group and above indication group were 86.2% (50/58) and 44.4% (8/18), respectively (p<0.05). The mean follow-up period was 42.2 ± 19.2 months. Total recurrence rates in the ESD group and operation group were 14.1% (9/76) and 0.7% (1/149), respectively (p<0.05). The main complication of ESD was bleeding (5.2%, 4/76). In the operation group, 2 (1.3%) patients died from postoperative bleeding and leakage of anastomosis site. ESD may be a feasible and safe treatment modality compared to that of surgical treatment for undifferentiated EGC when managed according to the expanded criteria. However, close endoscopic surveillance is required in this group because of higher incidence of intragastric recurrence.

Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal tumors: a meta-analysis.

To compare the efficacy and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for the treatment of colorectal tumors. Databases, such as PubMed, EMBASE, Cochrane Library and Science Citation Index updated to 2013 were searched to include eligible articles. In the meta-analysis, the main outcome measurements were the en bloc resection rate, the histological resection rate and the local recurrence rate. Meanwhile, we also compared the operation time and the incidence of procedure-related complications. Six trials were identified and a total of 1642 lesions were included. The en bloc resection rate was higher and the local recurrence rate was lower in the ESD group compared with the EMR group (OR = 7.94; 95%CI: 3.96-15.91; OR = 0.09; 95%CI: 0.04-0.19). There was no significant difference in histological resection rate(OR = 1.65; 95%CI: 0.29-9.30) and procedure-related complication rate between the two groups (OR = 1.59; 95%CI: 0.92-2.73). The meta-analysis also showed that ESD was more time consuming than EMR. Compared with EMR, ESD results in higher en bloc resection rate and lower local recurrence rate for the treatment of colorectal tumors, without increasing the procedure-related complications.

Evaluation of the application of endoscopic submucosal dissction in gastrointestinal cysts

To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for the treatment of gastrointestinal cysts. Clinicopathological data of 40 patients with gastrointestinal cyst undergoing ESD in our center during January 2008 and February 2012 were analyzed retrospectively. Complications, en bloc resection rate, and local recurrence were assessed. Eight lesions located in the esophagus, 11 in the stomach, 5 in the duodenum, and 16 in the colorectum. Thirty-seven lesions were successfully resected with ESD in an en bloc fashion (92.5%). During the operation, one perforation was encountered in the ascending colon and was clipped; one massive hemorrhage occurred in the esophagus and was treated with balloon compression. Postoperative pathological examination revealed cyst samples were intact without lesions in lateral and basal resection margins. Local recurrence was not found in 36 patients during a median postoperative follow-up of 9.7 months (range, 6-12 months). ESD is a safe and effective procedure for the treatment of gastrointestinal cysts.

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early esophageal cancer： a meta analysis

Objective Explore the differences in effectiveness and safety between endoscopic sub- mucosal dissection （ESD） and endoscopic mucosal resection （EMR） for early esophageal cancer （EEC）. Methods Papers published from January 1990 to December 2012 in Medline, Embase, Cochrane library, Wanfang, VIP and CNKI were searched in English and Chinese respectively to identify the studies comparing ESD with EMR for EEC. Meta-analysis for each outcome of the included studies that were identified by the inclusion criteria and the exclusion criteria was conducted using software Revman 5.1. Outcome measures consisted of three effectiveness-relevant measures （ rates of en bloc resection, curative resection, local recur- rence） and four safety-relevant measures （bleeding, perforation, stenosis and operation time）. Results A total of 8 non-randomized retrospective cohort studies （five full-text and three abstracts） were included. Me- ta-analysis showed significantly higher rates of en bloc resection [ 98.36% （560/366） vs. 41.79% （252/603）, P 〈0. 01 ], curative resection [90. 81% （168/185） vs. 50. 65% （ 194/383）, P 〈0. 01 ] and perforation [g. 51% （21/466） vs. 1.25% （8/640）, P =0.05] in ESD group compared with EMR group, and the rate of local recurrence was significantly lower in ESD group [ 0. 55% （2/366） vs. 13.76% （85/603）, P 〈0.01 ]. There were no significant differences in the rates of bleeding [0.21% （1/466） vs. 0.63%（4/640）, P =0.41] or stenosis [10.48% （39/372） vs. 10.15% （41/404）, P =0.89].Conclusion Compared with EMR, ESD showed obvious advantages of effectiveness and resemble risks for endoscopic resection of EEC, therefore ESD should be the first choice for endoscopic treatment of EEC. Key words: Meta-analysis ; Esophageal neoplasms ; Endoscopic submucosal dissection; Endo- scopic mucosal resectio

Poly(lactic acid-co-glycolic acid)–poly(ethylene glycol)–poly(lactic acid-co-glycolic acid) thermogel as a novel submucosal cushion for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a clinical therapy for early stage neoplastic lesions in the gastrointestinal tract. It is, however, faced with a crucial problem: the high occurrence of perforation. The formation of a submucosal fluid cushion (SFC) via a fluid injection is the best way to avoid perforation, and thus an appropriate biomaterial is vital for this minimally invasive endoscopic technique. In this study, we introduced an injectable thermogel as a novel submucosal injection substance in ESD. The hydrogel synthesized by us was composed of poly(lactic acid-co-glycolic acid)–poly(ethylene glycol)–poly(lactic acid-co-glycolic acid) (PLGA–PEG–PLGA) triblock copolymers. The polymer/water system was a low-viscosity fluid at room temperature and thus easily injected, and turned into a non-flowing gel at body temperature after injection. The submucosal injection of the thermogel to create SFCs was performed in both resected porcine stomachs and living minipigs. High mucosal elevation with a clear margin was maintained for a long duration. Accurate en bloc resection was achieved with the assistance of the thermogel. The mean procedure time was strikingly reduced. Meanwhile, no obvious bleeding, perforation and tissue damage were observed. The application of the thermogel not only facilitated the ESD procedure, but also increased the efficacy and safety of ESD. Therefore, the PLGA–PEG–PLGA thermogel provides an excellent submucosal injection system, and has great potential to improve the ESD technique significantly.

Endoscopic submucosal dissection using the “Clutch Cutter” for early esophageal squamous cell carcinoma

To reduce the risk of complications related to the use of knives in endoscopic submucosal dissection (ESD), we developed the Clutch Cutter which can grasp and incise targeted tissue using electrosurgical current, similarly to a biopsy technique. The study aim was to evaluate the efficacy and safety of ESD using the Clutch Cutter for early esophageal squamous cell carcinoma. ESD using the Clutch Cutter was performed on 32 consecutive patients with early esophageal squamous cell carcinoma. Therapeutic efficacy and safety were assessed. All lesions were treated easily and safely without unintended incision. En bloc resection was obtained in all patients. Histologically negative margins were obtained in 26/32 patients (81%). Endoscopic perforation due to the hood in one patient (3%), mediastinitis without endoscopic perforation in one patient (3%), and post-ESD stricture in 5 patients (16%) were observed. All were successfully managed conservatively. ESD using the Clutch Cutter appears to be a safe, easy, and technically efficient method for resecting early esophageal squamous cell carcinomas.

Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases

Objective. Subepithelial tumors (SETs) in the stomach are usually considered benign. However, some do have potential for malignant transformation, especially when originating in the muscularis propria (MP). Our study aimed to evaluate the clinical efficacy and safety of endoscopic submucosal dissection (ESD) for gastric SETs originating in MP. Material and methods. A total of 145 gastric MP SETs in 144 patients were treated by ESD between September 2008 and December 2012. Characteristics of patients and SETs, therapeutic outcomes, pathologic characteristics, complications and follow-up outcomes were evaluated. Results. Among the 144 patients, 104 were female (72.22%) and 40 were male (27.78%), and the mean age was 55.75 ± 11.29 years (range 18–78 years). The mean size of the tumors determined by endoscopic ultrasound (EUS) was 15.14 ± 9.70 mm (range 3–50 mm). En bloc complete resection was achieved in 134 of 145 tumors, giving a complete resection rate of 92.41%. The final histopathologic diagnoses included 52 leiomyomas, 89 gastrointestinal stromal tumors, 3 neurogenic tumors and 1 lipoma. Perforations occurred in 21 patients (14.48%) and were endoscopically repaired with clips or nylon bands. Intraoperative bleeding occurred in seven patients (4.83%) and was corrected with argon plasma coagulation (APC) or hot biopsy forceps. No local recurrence or distant metastasis was detected during a mean follow-up of 19.14 ± 10.29 months (range 3–51 months). Conclusions. ESD appears to be an effective and safe treatment for gastric SETs originating in MP.

Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in patients with chronic kidney disease

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), and the number of ESD performed for EGC in patients with chronic kidney disease (CKD) is increasing. Although patients undergoing hemodialysis tend to bleed and are at high risk for cardiovascular disease, the effectiveness and safety of ESD for EGC in patients with CKD in particular have not been established. The aim of this study was to evaluate the effectiveness and potential adverse effects of ESD for EGC in patients with CKD undergoing hemodialysis. Sixty-three consecutive CKD patients in whom 79 EGCs were treated by ESD between October 2004 and January 2012; 15 of the 63 patients were hemodialysis patients. Complete en bloc resection rate and ESD-related complications in hemodialysis patients versus non-hemodialysis patients were evaluated. The complete en bloc resection rate was 100% (15/15) in the hemodialysis patients and 87.5% (56/64) in the non-hemodialysis patients, respectively. The post-ESD bleeding rate was 33% (5/15) and 9% (6/64), respectively (P < 0.05). Perforation occurred only in non-hemodialysis patients; the incidence was 5% (3/64). Two ESD-related deaths occurred among hemodialysis patients (13%, 2/15); femoral artery infarction triggered post-ESD bleeding in one of these two patients, and alveolar hemorrhage occurred in the other. Hemodialysis poses a risk of post-ESD bleeding. We must understand this risk and provide countermeasures for post-ESD bleeding in hemodialysis patients.

Indications of endoscopic submucosal dissection for symptomatic benign gastrointestinal subepithelial or carcinoid tumors originating in the submucosa

Endoscopic submucosal dissection (ESD) for upper gastrointestinal (GI) subepithelial tumors (SETs) originating in the muscularis propria (MP) layer is associated with numerous issues regarding secure closure and measures against accidental perforation. However, symptomatic benign GI SETs or carcinoid tumors originating in the submucosa (SM) may be safely resected en-bloc using ESD. In this study, the feasibility and safety of ESD as a novel method for endoscopic resection for such GI SETs revealed on endoscopic ultrasonography (EUS) was investigated. A total of 12 consecutive cases of patients with symptomatic benign SETs (n=3; 1 esophageal hemangioma and 2 gastric lipomas) or small carcinoid tumors (n=9; <10 mm, with an extremely low risk of metastasis) originating in the SM as determined on EUS, between March, 2009 and April, 2013, were retrospectively reviewed. The lesions were resected by ESD after confirming that the tumors originated from the SM. The complication rate following en-bloc resection was also determined. En-bloc resection was achieved in all 12 cases, the mean procedure time was 45 min (range, 20-120 min) and no complications occurred intra- or postoperatively. There was no tumor recurrence or disease-related mortality reported during the follow-up period (median follow-up time, 13.4 months). Histopathological curative resection was achieved with ESD without complications in all 9 cases with carcinoid tumors. Therefore, if EUS reveals a SET originating in the SM without infiltration of the MP and resection is indicated due to the presence of abdominal symptoms, ESD may be a feasible option for diagnostic treatment with minimal invasiveness. However, larger-scale prospective studies are required to establish the feasibility and safety of this procedure.

The accumulating appreciation of endoscopic submucosal dissection in the treatment of gastrointestinal neoplasms: preliminary experience in local eastern China.

Endoscopic submucosal dissection (ESD), an emerging technique originated from Japan, has been introduced into China in recent years. The aim of this study was to evaluate the efficacy and safety of ESD in the treatment of gastrointestinal (GI) neoplasms. Early GI neoplasms (n=41) in 40 patients from local Eastern China were treated with ESD at Zhejiang Provincial People's Hospital and followed-up from January 2009 to December 2011. Postoperative pathology, complications and therapeutic outcomes were retrospectively analyzed. Mean size of the resected lesions was 2.2±0.81cm (1.2-6.0cm) and mean operation time was 77±28 minutes (20-150 minutes). The rates for successful resection, en bloc resection and complications were 90.2% (37/41), 83.8% (31/37) and 9.8% (4/41), respectively. The postoperative pathology showed 4 cases of early esophageal cancer, 6 of early gastric cancer or high-grade intraepithelial neoplastic changes, 5 of rectal laterally spreading tumor, 5 of esophageal or gastric leiomyoma, 2 of gastric heterotopic pancreas, and 18 of esophageal and gastric flat lesions with low-grade intraepithelial neoplastic changes. Tumor residue or recurrence was not been detected in all 40 patients during follow-up. According to our experience in local Eastern China, ESD is a feasible technique for the treatment of GI neoplasms. Even though it has promising resection rate and acceptable complication rate, the indication of ESD should be selected strictly and the operators need to be well-trained.

Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria

Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.

Endoscopic submucosal dissection using a carbon dioxide laser with submucosally injected laser absorber solution (porcine model)

Recently, endoscopic submucosal dissection (ESD) has been performed to treat early gastric cancer. The en bloc resection rate of ESD has been reported to be higher than that of conventional endoscopic mucosal resection (EMR), and ESD can resect larger lesions than EMR. However, ESD displays a higher complication rate than conventional EMR. Therefore, the development of devices that would increase the safety of ESD is desired. Lasers have been extensively studied as a possible alternative to electrosurgical tools. However, laser by itself easily resulted in perforation upon irradiation of the gastrointestinal tract. We hypothesized that performing ESD using a CO2 laser with a submucosal laser absorber could be a safe and simple treatment for early gastric cancer. To provide proof of concept regarding the feasibility of ESD using a CO2 laser with submucosally injected laser absorber solution, an experimental study in ex vivo and in vivo porcine models was performed. Five endoscopic experimental procedures using a carbon dioxide (CO2) laser were performed in a resected porcine stomach. In addition, three endoscopic experimental procedures using a CO2 laser were performed in living pigs. In the ex vivo study, en bloc resections were all achieved without perforation and muscular damage. In addition, histological evaluations could be performed in all of the resected specimens. In the in vivo study, en bloc resections were achieved without perforation and muscular damage, and uncontrollable hemorrhage did not occur during the procedures. Endoscopic submucosal dissection using a CO2 laser with a submucosal laser absorber is a feasible and safe method for the treatment of early gastric cancer.