Tunnel Dissection Research Articles

Magnetic multidirectional anchor-guided endoscopic submucosal tunnel dissection for large gastric lesions.

Magnetic multidirectional anchor-guided endoscopic submucosal tunnel dissection for large gastric lesions.

Первый успешный опыт эндоскопического лечения дивертикула Ценкера в Казахстане

Zenker's diverticulum tends to occur in the elderly and is generally a relatively rare disorder; the prevalence of Zenker's diverticulum is 1.5–5% of all esophageal diverticula. Men are affected 2-3 times more frequently than women. To date, Zenker's diverticulum is treated mostly by surgery in Kazakhstan, however, with the development of endoscopy the minimally invasive method, endoscopic diverticuloesophagostomy, is being implemented. The transoral treatment is aimed at creating the common cavity between the esophagus and the diverticulum in order to prevent food accumulation in the diverticulum. The anterior wall between these two structures consists of the diverticular wall, m. сricopharyngeus and esophagus wall, the septum transsection automatically ensures myotomy. Both open surgery and endoscopic transoral treatment of Zenker's diverticulum result in reduced symptoms in 94–100% of patients. The paper reports the first successful experience of the Zenker's diverticulum treatment by endoscopic submucosal tunnel dissection in Kazakhstan.

Endoscopic submucosal tunnel dissection with ring-thread countertraction for a large gastric tumor with extensive severe fibrosis

Various methods of traction have been reported for gastric endoscopic submucosal dissection (ESD). We report a successful case in which a new traction method combining a tunnel and a ring-thread counter traction was effective. The patient was a 78-year-old man with early gastric cancer; an 85-mm tumor was located at the lesser curvature of the upper gastric body (Fig. 1). The macroscopic type was 0-IIa, and there were no obvious findings of suspected submucosal invasive carcinoma, such as irregular protrusion, surface depression, and nonextension sign. Multiple ulcer scars were found on the anterior and posterior sides of the lesion. The histological type from the biopsy was well-differentiated tubular adenocarcinoma. The ESD was performed using a single-channel endoscope (GIF-Q260J; Olympus Co, Tokyo, Japan). The tumor resection devices used were the DualKnife (KD-650L, Olympus Co) and the ITknife2 (KD-611L, Olympus Co), and the solution for local injection was a mixture of 0.4% sodium hyaluronate and indigo carmine with diluted epinephrine. First, we made a circumferential incision; next we created the submucosal tunnel from the oral side to the anal side (Figs. 2 and 3). By creating the tunnel, the dissection line was clear in the fibrosis part of the anterior side, but we could not approach the posterior side because the fibrosis area was extensive. Therefore, we attached a ring-shaped thread (made of floss) with 2 endoclips to connect the oral side of the lesion to the greater curvature side (Fig. 4). In this case, the diameter of the ring was about 10 mm, and it was used to pull the lesion at the lesser curvature side of the stomach to the greater curvature side. The thread provided good traction for the fibrosis area and thus allowed us to perform submucosal dissection of the side of the tunnel (Fig. 5). Finally, the lesion was completely resected en bloc without any adverse events. The lesion was 85 x 60 mm in size, and histological examination revealed it to be well-differentiated intramucosal carcinoma, with no lymphovascular invasion. All of the margins were tumor-free (Fig. 6).Figure 3The submucosal tunnel was created from the oral side to the anal side.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4The ring-shaped thread was attached to connect the oral side of the lesion to the greater curvature side of the stomach.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Severe fibrosis area in the side of the tunnel, in which the dissection line became clearer after attaching the ring-shaped thread.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6The opened specimen revealed intramucosal carcinoma and negative margins; the lesion was 85 × 60 mm in size.View Large Image Figure ViewerDownload Hi-res image Download (PPT) For difficult lesions, it has been a problem to provide the traction to secure a good view in ESD. The effectiveness of endoscopic submucosal tunnel dissection (ESTD) has been reported as a good method for providing traction.1Feng X. Linghu E. Chai N. et al.Endoscopic submucosal tunnel dissection for large gastric neoplastic lesions: a case-matched controlled study.Gastroenterol Res Pract. 2018; 2018: 1419369Crossref PubMed Scopus (12) Google Scholar,2Zhang X. Shi D. Yu Z. et al.A multicenter retrospective study of endoscopic submucosal tunnel dissection for large lesser gastric curvature superficial neoplasms.Surg Endosc. 2019; 33: 1910-1919Crossref PubMed Scopus (16) Google Scholar However, ESTD alone did not provide enough traction in this case because of the lesion size and extensive severe fibrosis. In such a situation, combined use of traction by using ring-thread counter traction was effective (Fig. 7). Several techniques, such as “clip and snare” and “internal traction method,” which have been reported previously, were effective traction methods using similar devices.3Matsumoto K. Nagahara A. Sakamoto N. et al.A new traction device for facilitating endoscopic submucosal dissection (ESD) for early gastric cancer: the “medical ring.Endoscopy. 2011; 43: E67-E68Crossref PubMed Scopus (38) Google Scholar,4Baldaque-Silva F. Vilas-Boas F. Velosa M. et al.Endoscopic submucosal dissection of gastric lesions using the “yo-yo technique.Endoscopy. 2013; 45: 218-221Crossref PubMed Google Scholar However, those methods may require the assistant’s habituation or reinsertion of the endoscope, may have limited traction direction, or may not be suitable for large lesions. This method is considered to be simple and inexpensive, it does not require another assistant, it is suitable for large lesions, and it allows the operator to decide the direction of traction depending on the clip position. Based on this case, ESTD with ring-thread counter traction may be effective for large gastric tumors with extensive severe fibrosis (Video 1, available online at www.VideoGIE.org). All authors disclosed no financial relationships relevant to this article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlMmNjMGQ2NzQxODZmZjRkNzI3YjU3ZDFjMjg1ZDVhZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDY0ODkzfQ.gjaAez8j4Wr7199z-8bz3AYl8ncfOCfLRgaEsH4OE7H9yCZAYPnM0006xSLBE4vncFqGsiVdbvauHJcXsP5a3vC-PIUtJNyKU7KEaWLsQh59uksWMYqxRjTJS6X37IfWhWF8CjiUUNa-Jsfewy7I6agXdcaWiHProO0Fvkni2RUlSPSl7riUHuQpxZTt-NvxUrO8hvbcSSucxmz4OiHij1oXIFMAsliqITH7sHPk2foVQ7FKA_avs_kgdTgn_3OYBOO8R39XmswaCFGWvgvpmIAd4dFL6LJnyQKKAaN25BzdysFcTD6l_moN-MScWPBTDI2wG1sO02VNkwJlFtwROw Download .mp4 (73.36 MB) Help with .mp4 files Video 1A large gastric tumor with severe fibrosis was successfully resected by endoscopic submucosal tunnel dissection with ring-thread counter traction.

The Most Influential Publications on Endoscopic Submucosal Dissection: A Bibliometric Analysis

Background/Aims: Endoscopic submucosal dissection (ESD) is the first-line treatment for superficial gastrointestinal neoplasms with negligible lymph node metastasis. It has evolved through improvements in expertise and equipment, increased understanding of indications and short- and long-term outcomes, and better management of complications. This study aimed to assess and characterize the most influential publications in ESD research.Materials and Methods: We searched the top 50 most cited articles using Web of Science Core Collection (WoSCC) and Google Scholar (GS) from the inception of these services to January 2019. The top 50 Altmetric Attention Score (AAS) articles based on online media mentions were also searched. Each article was evaluated for the number of citations, title, journal, and publication year.Results: The number of citations for the top 50 WoSCC articles on ESD ranged from 37 to 199; Endoscopy published the most articles (20%). Among the top 50 GS articles, Gastrointestinal Endoscopy published the most ESD articles (34%) and the most shared AAS articles (42.6%). PubMed Central article citations in WoSCC or GS showed significant correlation with those from each metric, unlike AAS. The words with the highest relevance scores were “submucosal tunnel dissection,” “guideline,” “novel submucosal gel,” “adhesive material,” “cell sheet,” “esophageal ulcer,” “hemospray,” and “endoscopic closure,” while the following words were influential: “meta-analysis,” “esophageal stricture,” “perforation,” “bleeding,” “fibrin glue,” “artificial ulcer,” “porcine model” and “esophageal squamous cell neoplasia,” excluding “ESD.”Conclusions: This study presents a detailed list of influential articles, journals, and topic words.

Autologous skin-grafting surgery to prevent esophageal stenosis after complete circular endoscopic submucosal tunnel dissection: a case-matched controlled study.

The incidence of postoperative stenosis after endoscopic resection of wholly circumferential superficial esophageal squamous cell neoplasms (SESCNs) is extremely high. Between January 2011 and April 2019, 19 patients who underwent autologous skin-grafting surgery (ASGS) after complete circular endoscopic submucosal tunnel dissection (ccESTD) were enrolled to form the ASGS group. Cases in the ASGS group were individually matched at a 1:1 ratio to cases undergoing fully covered esophageal stent (FCES) placement alone (FCES group) based on pathological diagnosis, curative resection, longitudinal length of ulceration, lack of stent migration, time to stent removal, follow-up period and operators. Baseline characteristics and treatment outcomes were compared between the two groups. Baseline characteristics were comparable between the ASGS group and the FCES group. The incidence of patients with esophageal stenosis after removal of the stent in the ASGS group was significantly reduced compared that in the FCES group (36.8% vs 78.9%, p = 0.020). Comparison of preventive methods (ASGS vs FCES alone) between the stenosis group and nonstenosis group revealed that ASGS accounted for a higher proportion than FCES alone in the nonstenosis group (p = 0.020). Compared with FCES placement alone, ASGS appeared to be more effective in preventing esophageal stenosis after ccESTD for SESCNs.

Efficacy and safety of endoscopic submucosal tunnel dissection for rectal laterally spreading tumors.

Evidence that comprehensively compares the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) with endoscopic submucosal dissection (ESD) for rectal laterally spreading tumors (LSTs) is limited. Between January 2009 and June 2018, 143 rectal LSTs in 143 patients who had undergone either ESD (n = 84) or ESTD (n = 59) were included in the study. One-to-one propensity score matching (PSM) was performed, and 50 pairs were selected. The data on patient demographics, treatment information, pathology reports, adverse events and follow-up were collected. Before PSM, the median specimen area was significantly larger in the ESTD group than in the ESD group (12.56 cm2 vs. 6.32 cm2, respectively; p < 0.001). The median dissection speed was significantly higher in the ESTD group than in the ESD group (24.53 mm2/min vs. 15.16 mm2/min, respectively; p < 0.001). After PSM, the median dissection speed was significantly higher in the ESTD group than in the ESD group (23.80 mm2/min vs. 17.12 mm2/min, respectively; p < 0.001). In multiple linear regression analysis, significant factors related to a higher dissection speed were the treatment method of ESTD (p < 0.001) and larger specimen area (p < 0.001). ESTD appears to be a safe and effective method to treat rectal LSTs. Compared with ESD, ESTD appears to achieve a higher dissection speed for rectal LSTs.

Efficacy and safety of endoscopic submucosal tunnel dissection vs endoscopic submucosal dissection for early superficial upper gastrointestinal precancerous lesions and tumors: A meta-analysis.

Endoscopic submucosal tunnel dissection (ESTD) is a new treatment for superficial upper gastrointestinal precancerous lesions and tumors. However, its safety and efficacy for treating these lesions is still uncertain. This meta-analysis aimed to compare the efficacy and safety of ESTD with those of endoscopic submucosal dissection (ESD) in treating early superficial upper gastrointestinal precancerous lesions and tumors. Electronic databases, including EMBASE, PubMed, Cochrane Library and the Web of Science, were systematically searched for articles published up to 1 April 2020. The primary outcomes were complete and en bloc resection rates of the lesions. The secondary outcomes included operation time, speed of dissection, complication and recurrence rates. The Newcastle-Ottawa quality assessment scale was used to evaluate the quality of the studies. Seven studies were included in the final meta-analysis. The complete and en bloc resection rates of early superficial esophageal lesions as well as the en bloc resection rate of early superficial gastric lesions were similar between the ESTD and ESD groups. Compared with the ESD group, the ESTD group had a higher en bloc resection rate for early superficial gastric lesions. A faster dissection speed was observed in both superficial esophageal and gastric lesions. In gastric lesions, the operation time of the ESTD group was shorter than that of the ESD group, while it did not differ for esophageal lesions. There were no obvious differences in bleeding and perforation rates between the groups. As an endoscopic technique for treating early superficial upper gastrointestinal lesions, ESTD is as safe as and more effective than ESD, especially for gastric lesions.

Efficacy of endoscopic submucosal tunnel dissection versus endoscopic submucosal dissection for superficial esophageal neoplastic lesions: a systematic review and meta-analysis.

To evaluate the effectiveness of endoscopic submucosal tunnel dissection (ESTD) and endoscopic submucosal dissection (ESD) in superficial esophageal neoplastic lesions (SENL). A comprehensive search for studies investigating the efficacy of ESTD and ESD for SENL was conducted to search for relevant studies through PubMed, Web of Science, Cochrane Library, SinoMed, CNKI, and Wanfang.Weighted pooled rates were calculated for en bloc resection rate, R0 resection rate, operation time, dissection area, dissection speed, and adverse events. The 95% confidence intervals (95%CI) for effect size were used to calculate the pooled value using the fixed- or random-effects model. A total of seventeen studies with 1161 patients were identified and included in the meta-analysis.The pooled analysis showed that ESTD had significantly higher en bloc resection (OR 3.98; 95% CI 1.74 to 9.12; p = 0.001) and R0 resection rates (OR 2.29; 95% CI 1.54 to 3.46; p < 0.001) than ESD.The operation time in the ESTD group was shorter than that in the ESD group (SMD = -0.57; 95% CI -0.95 to -0.19; p = 0.003). The dissection area of the ESTD group was larger than that in the ESD group (SMD = 0.49; 95% CI 0.16 to 0.83; p = 0.004), and the dissection speed is faster than that in the ESD group (SMD = 1.52; 95%CI 1.09 to 0.83; p < 0.001). There were no significant differences in esophageal stenosis (p = 0.94) between the two techniques. However, ESTD was superior to ESD in other adverse events (p < 0.05). ESTD has a significant advantage over ESD in the treatment of SENL. ESTD has significantly higher en bloc and R0 resection rates and reduced adverse events.

Endoscopic Esophageal Submucosal Tunnel Dissection for Cystic Lesions Originating from the Muscularis Propria of the Gastric Cardia.

Objective To analyze the types and properties of cystic lesions originating from the muscularis propria of the gastric cardia (CLMPGC), explore the growth pattern and anatomical characteristics, and evaluate the safety, feasibility, and clinical efficacy of endoscopic esophageal submucosal tunnel dissection (ESTD). Methods From September 2013 to July 2018, we treated 6 patients with CLMPGC whom we had diagnosed using endoscopy, endoscopic ultrasound (EUS), and Computed Tomography (CT) before the operations. ESTD was the best option for treatment for all these patients. Postoperative observation and follow-ups were performed, and the operational, clinical data, and treatment results are analyzed. Results The mean age of the patients was 50.67 ± 11.59 years (male : female = 1 : 1). The only clinical manifestations the patients exhibited were upper abdominal discomfort. The diameter of the masses was 2.05 ± 0.73 (1.1–3.0) cm. The duration of the ESTD operation was 93.5 (82–256) mins, and the length of hospital stay was 7.50 ± 1.38 days. Postoperative pathology showed 4 cases of an epithelioid cyst, and 2 cases of mucocele with xanthogranuloma. There were no complications, such as hemorrhage, pneumothorax, and pleural effusion during and after the operation. No recurrence during the follow-ups was observed. Conclusion The CLMPGC were mainly mucocele and epidermoid cyst, in an expansive growth pattern, and these lesions had no distinct borders with the muscularis propria. The muscularis propria formed a complete wall of the lesion. There was no direct blood supply to the lesions from big blood vessels. Endoscopic esophageal submucosal tunnel dissection was a safe, feasible, and effective treatment for CLMPGC.

Mo1670 EFFICACY AND SAFETY OF ESTD AND ESD IN THE TREATMENT OF LARGE AREA RECTAL LATERALLY SPREADING TUMORS

This study aims to compare the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) and endoscopic submucosal dissection (ESD) in the treatment of large area rectal laterally spreading tumors (LST). The clinical data, operation procedures and pathology of rectal LST treated with ESD and ESTD from August 2011 to February 2019 in the Center of Digestive Endoscopy, West China Hospital of Sichuan University were retrospectively analyzed. The rates of en bloc, curative resection, complications and recurrence of tumors were compared and analyzed, then we evaluated the safety and effectiveness of ESD and ESTD in the treatment of large area LSTs. There were 122 patients with rectal LST in ESD and ESTD groups. The lesion area was 12.6±14.1 cm2, 24.5±19.9 cm2, respectively, p < 0.001.;the en bloc resection rate was 88.3% ,97.8%,respectively,p=0.066; the dissection speed was 23.3±18.3 mm2/min, 27.1±13.2 mm2/min, respectively, p=0.239; the curative resection rate was 98.7%, 86.7%, respectively,p=0.006; There were 7 cases of non-curative resection in the two groups after operation, of which 6 cases underwent additional surgery. Postoperative complications were mainly fever and hematochezia without endoscopic intervention, with fewer serious complications. The overall canceration rate of LST was 17.3%. The follow-up time of the two groups was 16.4 ±16.0 months and 23.20±16.3 months, respectively. Only one case recurred in ESD group. In the analysis of large area lesions(>3cm), there were 90 patients with large area LST, 50 patients in ESD group and 40 patients in ESTD group .The lesion areas of the two groups was 17.4±15.5 cm2 , 26.0±19.8cm2, respectively, p=0.025;the en bloc resection rate was 85%, 97.5%, respectively, p=0.034; the dissection speed was 28.4±20.3 mm2/min, 28.3 ±12.9 mm2/min, respectively, p=0.991; the curative resection rate was 92.5%, 100%, respectively, p=0.084. Both ESD and ESTD can safely and effectively resect rectal LST, which was not affected by the size of lesions. There was no significant difference in the dissection speed and the curative resection rate. When large area LST was resected, the rate of en bloc resection of ESTD was higher than that of ESD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endoscopic submucosal tunneling dissection: use of a novel bipolarradiofrequency and microwave-powered device for colorectal endoscopic submucosal dissection.

Endoscopic submucosal tunneling dissection: use of a novel bipolarradiofrequency and microwave-powered device for colorectal endoscopic submucosal dissection.

Autologous esophageal mucosa with polyglycolic acid transplantation and temporary stent implantation for the prevention of esophageal stenosis after circumferential endoscopic submucosal dissection.

Autologous esophageal mucosa with polyglycolic acid transplantation and temporary stent implantation for the prevention of esophageal stenosis after circumferential endoscopic submucosal dissection.

Salvage endoscopic submucosal tunneling dissection using an electrosurgical knife for an elderly patient with circumferential residual esophageal squamous cell carcinoma after radiotherapy.

Salvage endoscopic submucosal tunneling dissection using an electrosurgical knife for an elderly patient with circumferential residual esophageal squamous cell carcinoma after radiotherapy.

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal neoplastic lesions: a systematic review and meta-analysis

BackgroundPresently, endoscopic submucosal tunnel dissection (ESTD) has been a novel therapy for superficial esophageal neoplastic lesions (SENL), especially for circumferential neoplastic lesions. A number of studies have reported the clinical application of ESTD with promising outcomes. Therefore, we conducted a systematic review and meta-analysis to evaluated the efficacy and safety of ESTD for SENL .MethodsFrom 2013 to November 2018, Pubmed, Embase and Cochrane databases were searched to determine studies reporting ESTD treatment of SENL. Weighted pooled rates (WPR) were calculated for en bloc resection, R0 resection and complication of ESTD. Risk ratios (RR) were calculated and pooled to compare the clinical outcomes of ESTD with ESD for SENL.ResultsA total of 9 studies involving 494 patients with 518 esophageal neoplastic lesions were included in our study. WPR for en bloc resection and R0 resection of ESTD was 97.0% (95% CI: 94.7–98.3%) and 84.1% (95% CI: 80.5–87.1%), respectively. WPR for complication was 40.0% (95% CI: 25.8–56.1%). Two studies with 265 patients compared the performance of ESTD with ESD. Pooled RR for en bloc resection and R0 resection was 1.04 (95% CI: 0.95–1.14, P = 0.42) and 1.01 (95% CI: 0.93–1.10, P = 0.73), respectively. Pooled RR for complication was 0.68 (95% CI: 0.46–1.01, P = 0.05).ConclusionOur study showed that ESTD is effective for treating SENL with high en bloc resection rate and R0 resection rate, but accompanying by a relatively high complications.

Efficacy of crystal violet for identifying the distal end in esophageal submucosal tunnel resection

Background Endoscopic submucosal tunnel dissection (ESTD) has recently been an effective procedure for resecting large early esophageal neoplasm. However, excessive dissection beyond the distal limit may occur because the prepared distal end often cannot be distinguished through the tunnel. This study aimed to assess the efficacy and safety of a novel crystal violet navigation (CVN) for identifying the distal end. Material and methods In the observational case series study, all 22 patients who underwent esophageal ESTD using the CVN were included. When setting the distal end, the distal incision line was dyed purple using a crystal violet solution. The rates of purple color identified via the tunnel, successful tunnel penetration without extra dissection, en bloc and curative resection, procedure time for ESTD and CVN, and procedure-associated complications were evaluated. Results The rates of purple color and successful tunnel penetration were both 100%. En bloc and curative resection were 100%, and 86%, respectively. The mean total procedure time was 103.9 ± 46.2 (mean ± SD) minutes, while the mean time for the CVN was 14.1 ± 3.44 s. No complications were observed. Conclusions The simple CVN method can be a navigation tool for identifying the distal end during the ESTD procedure.

Capacity of flexible endoscopy in subepithelial esophageal tumors

Aim of the study was to investigate the results of endoscopic diagnostics and peroral operative endoscopy in subepithelial esophageal tumors. Material and methods. Data of 21 patients underwent flexible endoscopic interventions for subepithelial esophageal tumors (SET) from 2016 till 2019 were analyzed. Main endoscopic methods to reveal and characterize tumors preoperatively are examination in white light, narrow light spectrum imaging, radial endoscopic ultrasonographic scanning. Tumors from 8 till 40 mm in maximal dimension removed by endoscopic mucosal resection (2 tumors in 1 patient), tunnel dissection (13 cases) or endoscopic submucosal dissection (7 cases). The additional endoscopic ultrasonography was demanded intraoperatively in 2 cases of difficult tumor location and blurry visualization. Results and discussion. Subepithelial esophageal tumors are mainly diagnosed occasionally in patients without symptoms related to tumor. Suspicion of the tumor was based on routine esophagogastroduodenoscopy. Following endoscopic ultrasonography of planned esophageal segment allowed rejecting or confirming the lesion (21 patients), evaluating its echoscopic structure, size, growth direction, intramural location and connection to wall layers to make an assumption related to tumor morphology, to plan way of tumor removal. We choose interventions in depends on combination of available tumor features. Technical success of endoscopic interventions with use of flexible endoscope under this approach is noted in all the patients. So endoscopic methods are important for primary and detailed diagnostics and also effective for operative treatment in cases of appropriate indications.

Treatment of ureteral tunnel in laparoscopy radical hysterectomy

We introduce an approach for making a ureteral tunnel with the aim of illustrating the importance of finding the tunnel dissection of the tissue spaces. The key to radical hysterectomy is identifying the tissue space that naturally exists between tissues rather than clamping a manual tunnel. For example, the urogenital sinus and Müllerian duct are very near each other; however, they never completely merge together. The method for finding the tunnel and avoiding the manual clamping of tunnels will maximally reduce intraoperative bleeding. Furthermore, the instructional significance of the surgery makes this technique worthy of promotion. Its main aspects include finding the gap, reducing or eliminating tunnel bleeding, and reducing collateral damage.

Clinical outcomes of endoscopic submucosal tunnel dissection compared with conventional endoscopic submucosal dissection for superficial esophageal cancer: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer. However, it has limitations in case of large superficial esophageal squamous cell neoplasms (SESCNs), in which submucosal injection cannot attain satisfactory lifting effects. Thus, endoscopic submucosal tunnel dissection (ESTD) was introduced as a new treatment for SESCNs presenting satisfying results. Many studies have tried to verify the efficacy of ESTD, yet no meta-analysis has been published until now. We searched the databases of PubMed, Cochrane Library, Web of Science, SinoMed, Wanfang, and CNKI dating up to February 1, 2019. Studies comparing the clinical outcomes of ESTD and ESD for superficial esophageal cancers were enrolled. The Newcastle-Ottawa Quality Assessment Scale was used to evaluate the quality of these studies. Eight articles were included that involved a total of 625 superficial esophageal cancer patients. Our analysis revealed that ESTD is superior to ESD as it has higher en bloc resection rate, shorter operation time, and lower recurrence rate 1 year after operation. The R0 resection rate and postoperative adverse event rate of ESTD group is comparable with ESD group. Our study implicates that ESTD is a potentially superior treatment to ESD for superficial esophageal cancer.

Branching Pattern of the Medial Calcaneal Neurovascular Bundle in Porta Pedis of the Human Foot

The medial calcaneal nerve (MCN) is the first branch of the posterior tibial nerve (PTN) in the porta pedis, enervates the skin of the heel and medial side of the foot. Heel pain is a common condition encountered by physicians, and this may have a significant clinical association with the MCN’s branching pattern. This study was to identify branching pattern variations in the medial calcaneal neurovascular bundle. This study was carried out using 60lower limbs of formalin-embalmed cadavers, using the tarsal tunnel dissection method for 30right and 30 left lower limbs. The medial calcaneal neurovascular bundle course was identified by exposing the PTN and its branches from the distal end of the leg toward the plantar surface beyond its bifurcation and resecting the skin and flexor retinaculum. Many MCN branching pattern variations (specifically concerning origins, numbers, and levels of branching) were observed. In the right foot a single branch was present in 21 specimens (70%), while two branches were observed in nine specimens (30%). In the left foot, a single branch was present in 22 specimens (73.3%) and two branches were present in 8 specimens (26.7%). In this study, two branches originate from lateral planter artery is the most common observation. This study concludes that a single MCN originating from the TN is the most common variant. Two medial calcaneal arteries (MCAs) originating from the LPA is also common.

Comparison of Short-Term Efficacy Between Endoscopic Submucosal Tunnel Dissection and Endoscopic Submucosal Dissection in Treatment of Wide Esophageal Squamous Cell Carcinoma of Early Stage.

The goal of this study was to compare the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) with endoscopic submucosal dissection (ESD) for the removal of early-stage esophageal squamous cancer wider than or equal to one half the circumference of the esophagus. Although ESD has been successfully applied for resection of early-stage esophageal cancer, there are still technical challenges and postoperative stenosis when it is applied to treat large lesions. A total of 40 patients with early-stage esophageal cancer wider than or equal to one half its circumference were enrolled in this study and randomly assigned to an ESTD or ESD group for treatment of esophageal superficial squamous cell carcinoma. All of the patients received oral steroids after endoscopic dissection. We then compared the 2 groups in terms of average operating time, dissection speed, en bloc resection rate, R0 resection rate, and complications during a 1-year follow-up period. The dissection speed in the ESTD group was significantly faster than that in the ESD group (P=0.047). There were no significant differences in operating time, en bloc resection rates, or R0 resection rates between the ESTD and ESD group (P=0.319, 1.000, 1.000, respectively). There were also no significant differences in perforation, bleeding, or stenosis rates between the ESTD and ESD group (P=1.000, 0.748, 1.000, respectively). Both ESTD and ESD are safe and effective therapies for early-stage esophageal cancer wider than or equal to one half the esophageal circumference. The dissection speed of ESTD is faster than that of ESD.