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Mukkada RJ, Mathew PG. Knives in Third Space. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1750128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractEndoscopic mucosal resection (EMR) has always been done with a snare. The maximum diameter of the snare is usually 2 cm and the largest lesion that can be removed in one piece is usually maximum of 2 cm. In EMR, after the elevation of the submucosa, snares are used for the resection of the mucosal lesion; however, for endoscopic submucosal dissection (ESD), special knives are required, which have various uses in different areas of the gastrointestinal tract. ESD knives have developed and evolved over the past 30 years allowing it to be performed safely. It allows very precise cutting of the mucosa as well as dissection of the submucosal tissue planes. This review discusses some of the more commonly used knives.
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Affiliation(s)
- Roy J. Mukkada
- Department of Gastroenterology, VPS Lakeshore Hospital, Kochi, Kerala, India
| | - Pradeep G. Mathew
- Department of Gastroenterology, VPS Lakeshore Hospital, Kochi, Kerala, India
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Chen S, Zhou D, Yu J, Ruan R, Liu Y, Li Y, Shen Q, Wang S. A Novelly Developed Bipolar Needle Knife Can Be an Alternative Device Choice for Endoscopic Submucosal Dissection (With Video). Front Med (Lausanne) 2022; 9:888635. [PMID: 35646964 PMCID: PMC9136242 DOI: 10.3389/fmed.2022.888635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022] Open
Abstract
Background Endoscopic submucosal dissection (ESD) is technically difficult with high rates of complications, such as perforation and bleeding. We aimed to explore the safety and cutting efficiency of a novelly devised bipolar knife for ESD procedure. Methods Taking a traditional monopolar knife as a reference, the safety and feasibility of the novel bipolar knife were evaluated by an animal experiment and a human study. Furthermore, we assessed the usefulness and advantage of this novel bipolar knife by using the finite element method. Results A porcine experiment confirmed that there was no significant difference in wound size and cutting speed between the monopolar and bipolar knives. The thermal damage and histopathological scores produced by the two knives were similar. In addition, the porcine experiment and patients' study identified that the incidence of postoperative complications, such as bleeding, perforation, and infection, had no statistical difference between the monopolar and bipolar groups. Finally, the finite element model showed that the length and depth of thermal damage caused by the bipolar knife were, respectively, 102.77–117.98% and 80.87–84.53% of those caused by the monopolar knife at the same power. Conclusion The novel bipolar knife was theoretically safer than the monopolar knife and, at least, was confirmed not inferior to the monopolar knife in operability and cutting efficiency. Thus, the novel bipolar knife can be an alternative device choice for ESD.
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Bai Y, Yang F, Liu C, Li DF, Wang S, Lin R, Ding Z, Meng WB, Li ZS, Linghu EQ. Expert consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy (2020, Shanghai). J Dig Dis 2022; 23:2-12. [PMID: 34953023 DOI: 10.1111/1751-2980.13074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/11/2022]
Abstract
High-frequency electrosurgery has been widely applied in digestive endoscopy with constantly expanding indications. However, high-frequency electrosurgery may cause possible complications such as hemorrhage or perforation during or after the procedure, of which endoscopists must be cautious. Digestive endoscopists must have a firm grasp of the principles of high-frequency electrosurgery as well as its safety issues so as to improve the safety of its clinical application. To this end, experts in gastroenterology and hepatology, digestive endoscopy, surgery, nursing and other related fields were invited to draft a consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy based on relevant domestic and international literatures and their experiences.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Fan Yang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Cui Liu
- Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - De Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong Province, China
| | - Shi Wang
- Endoscopy Center, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, Zhejiang Province, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Wen Bo Meng
- Department of General Surgery, First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - En Qiang Linghu
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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Esaki M, Ihara E, Gotoda T. Endoscopic instruments and techniques in endoscopic submucosal dissection for early gastric cancer. Expert Rev Gastroenterol Hepatol 2021; 15:1009-1020. [PMID: 33909540 DOI: 10.1080/17474124.2021.1924056] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Endoscopic submucosal dissection (ESD) is a less invasive local treatment for early gastric cancer (EGC).Areas covered: Japanese guidelines have recently expanded the endoscopic treatment indications for EGC. ESD is sometimes performed for lesions with a relative indication that has not previously been considered for ESD. ESD procedures are technically difficult, especially for larger and more invasive lesions. Complete resection and accurate histological assessment of EGC lesions are essential to evaluate endoscopic curability. Various endoscopic instruments, including three types of endoscopic knives and specific hemostatic forceps, have been developed, and endoscopic techniques, including the traction method, have been modified to simplify the procedure.Expert opinion: An insulated-tip knife with large tissue contact allows us to perform faster incisions, while a needle-type knife with minimal tissue contact allows us to perform precise incisions. Furthermore, a scissor-type knife with grasping tissues allows us to perform more secure incision. The traction method enables the operator to proceed with submucosal dissection procedures. In cases with small lesions, snaring can be used, as well as knife dissection. Understanding the features of each endoscopic instrument and technique is essential because appropriate selection and usage contribute to successful and safe ESD procedures.
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Affiliation(s)
- Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
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Endoscopic submucosal dissection for colorectal laterally spreading tumors with the Dual knife only. Wideochir Inne Tech Maloinwazyjne 2019; 14:495-500. [PMID: 31908694 PMCID: PMC6939212 DOI: 10.5114/wiitm.2019.84217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/10/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction The knives for endoscopic submucosal dissection (ESD) have their strengths as well as shortcomings. They need to be used in combination in most cases. The Dual knife is a relatively novel type of ESD knife produced in 2009, which can be used for completing the whole procedure of ESD. Aim Colorectal laterally spreading tumors (LSTs) are a special subtype of colorectal neoplasms. We aimed to evaluate the clinical features and outcomes of ESD for colorectal LSTs only using the Dual knife from our experience. Material and methods This retrospective study included 162 patients (each patient had 1 lesion) with colorectal LSTs treated by ESD with the Dual knife by a single endoscopist at our hospital between June 2015 and January 2018. We analyzed the clinical features and outcomes after resection. Results We obtained the en bloc ESD of the colorectal LSTs and the complete histological assessment in all patients. The mean age of the patients was 53.9 years. The mean diameter of lesions was 46 mm. The most common location of LSTs was the rectum. The most common histological type was tubular adenoma with 63 cases. The mean operating time was 56 min. Perforation and bleeding rates were 0.6% and 0.6%, respectively. No cases of local persistence or recurrence were observed at a follow-up endoscopy 6 to 31 months after the en bloc resection. Conclusions The ESD using the Dual knife only for colorectal LSTs has the advantages of safety, efficiency, and minimally invasiveness. It is worthy of widespread clinical application.
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The superficial elevated and depressed lesion type is an independent factor associated with non-curative endoscopic submucosal dissection for early gastric cancer. Surg Endosc 2016; 30:4880-4888. [DOI: 10.1007/s00464-016-4825-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 02/09/2016] [Indexed: 01/09/2023]
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Thread-Traction with a Sheath of Polypectomy Snare Facilitates Endoscopic Submucosal Dissection of Early Gastric Cancers. Gastroenterol Res Pract 2015; 2016:9415497. [PMID: 26843860 PMCID: PMC4710898 DOI: 10.1155/2016/9415497] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/13/2015] [Indexed: 02/07/2023] Open
Abstract
Although the thread-traction (TT) method has been found useful during endoscopic submucosal dissection (ESD) for early gastric cancers, the movement of the thread interferes with the movement of the endoscope, and the lesion can only be pulled to the mouth side. We have developed the novel TT method using a sheath of polypectomy snare (TTSPS). The TTSPS method enables free and independent movement of the thread and the endoscope and allows pulling the lesion towards the anal as well as oral side. The median dissection times, numbers of instances of arterial bleeding, and numbers of local injections into the submucosal layer were significantly lower for ESD with TTSPS than for conventional ESD. Countertraction ESD using the TTSPS method is straightforward, safe, easy, noninvasive, and cost effective, and it uses instruments readily available in most hospitals to enhance visualization of cutting lines. Therefore, the TTSPS method can be universally applied in conventional ESD.
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Nishizawa T, Suzuki H, Akimoto T, Maehata T, Morizane T, Kanai T, Yahagi N. Effects of preoperative proton pump inhibitor administration on bleeding after gastric endoscopic submucosal dissection: A systematic review and meta-analysis. United European Gastroenterol J 2015; 4:5-10. [PMID: 26966517 DOI: 10.1177/2050640615588023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/29/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIM The efficacy of using proton pump inhibitors (PPIs) prior to gastric endoscopic submucosal dissection (ESD) to reduce gastric bleeding remains controversial. This study aimed to systematically review the literature to evaluate the efficacy of preoperative PPI use to reduce post-ESD bleeding. METHODS PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched to identify randomized trials eligible for inclusion in the systematic review. Data from four studies (406 patients) were combined to calculate a pooled risk difference (RD) for developing post-ESD bleeding. RESULTS Compared with patients who received no premedication, the pooled RD for post-ESD bleeding in patients who received preoperavive PPI was -0.027 (95% confidence interval: -0.070-0.017, p = 0.228), without significant heterogeneity. Preoperavive PPI use significantly increased gastric pH (weighted mean difference: 1.289, 95% CI: 0.227-2.352, p = 0.0174). CONCLUSIONS This systematic review and meta-analysis showed that premedication with PPI had no advantage for the prevention of post-ESD bleeding, despite increasing gastric pH.
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine, Tokyo, Japan; Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine, Tokyo, Japan
| | | | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine, Tokyo, Japan
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Espinel J, Pinedo E, Ojeda V, Rio MGD. Multiband mucosectomy for advanced dysplastic lesions in the upper digestive tract. World J Gastrointest Endosc 2015; 7:370-380. [PMID: 25901216 PMCID: PMC4400626 DOI: 10.4253/wjge.v7.i4.370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/20/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic resection (ER) is at present an accepted treatment for superficial gastrointestinal neoplasia. ER provides similar efficacy to surgery; however, it is minimally invasive and less expensive. Endoscopic mucosal resection (EMR) is superior to biopsy for diagnosing advanced dysplasia and can change the diagnostic grade and the management. Several EMR techniques have been described that are alternatively used dependent upon the endoscopist personal experience, the anatomic conditions and the endoscopic appearance of the lesion to be resected. The literature suggests that EMR offers comparable outcomes to surgery for selected indications. EMR techniques using a cap fitted endoscope and EMR using a ligation device [multiband mucosectomy (MBM)] are the most frequently use. MBM technique does not require submucosal injection as with the endoscopic resection-cap technique, multiple resections can be performed with the same snare, pre-looping the endoscopic resection-snare in the ridge of the cap is not necessary, MBM does not require withdrawal of the endoscope between resections and up to six consecutive resections can be performed. This reduces the time and cost required for the procedure, while also reducing patient discomfort. Despite the increasing popularity of MBM, data on the safety and efficacy of this technique in upper gastrointestinal lesions with advanced dysplasia, defined as those lesions that have high-grade dysplasia or early cancer, is limited.
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Nishizawa T, Suzuki H, Kinoshita S, Goto O, Kanai T, Yahagi N. Second-look endoscopy after endoscopic submucosal dissection for gastric neoplasms. Dig Endosc 2015; 27:279-84. [PMID: 25423881 DOI: 10.1111/den.12410] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/21/2014] [Indexed: 02/06/2023]
Abstract
Routine second-look endoscopy after gastric endoscopic submucosal dissection (ESD) remains controversial. The aim of the present study was to systematically evaluate the efficacy of second-look endoscopy for gastric ESD. PubMed, the Cochrane library, and the Igaku-chuo-zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data were combined to calculate a pooled odds ratio (OR) for developing post-ESD bleeding. The database search yielded three randomized trials (854 patients). Compared with second-look endoscopy, the pooled OR for post-ESD bleeding without second-look endoscopy was 0.69 (95% confidence interval [CI]: 0.38-1.26, P = 0.228), without significant heterogeneity. There were no significant differences between second-look endoscopy and no second-look endoscopy with regard to large tumor size (>20 mm). This systematic review and meta-analysis showed that second-look endoscopy had no advantage for the prevention of post-ESD bleeding in patients without a high risk of bleeding.
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Efficacy and safety of a novel submucosal lifting gel used for endoscopic submucosal dissection: a study in a porcine model. Surg Endosc 2014; 29:2651-60. [DOI: 10.1007/s00464-014-3985-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 11/04/2014] [Indexed: 12/28/2022]
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Nishizawa T, Suzuki H, Matsuzaki J, Kanai T, Yahagi N. Propofol versus traditional sedative agents for endoscopic submucosal dissection. Dig Endosc 2014; 26:701-6. [PMID: 25115459 DOI: 10.1111/den.12342] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Propofol has been suggested to be superior to benzodiazepines when used as a sedative agent for endoscopic examination. The aim of the present study was to systematically evaluate the safety and efficacy of propofol sedation for endoscopic submucosal dissection (ESD). METHODS PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data from the eligible studies were combined to calculate pooled odds ratios (OR) of developing restlessness, full awakening at 1 h post-ESD, hypoxia, and hypotension. RESULTS We identified three randomized trials (298 patients) from the database search. Compared with traditional sedative agents, the pooled OR of restlessness and full awakening at 1 h post-ESD with propofol sedation were 0.41 (95% confidence interval [CI]: 0.21-0.81) and 8.59 (95% CI: 4.29-17.2), respectively, without significant heterogeneity. Compared with traditional sedative agents, the pooled OR of hypoxia and hypotension with propofol sedation were 1.13 (95% CI: 0.58-2.21) and 0.92 (95% CI: 0.25-3.41), respectively, indicating no significant differences between the groups. CONCLUSION Propofol sedation during ESD is more effective as compared with traditional sedative agent. The risk of complications is similar.
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Hammad H, Kaltenbach T, Soetikno R. Endoscopic submucosal dissection for malignant esophageal lesions. Curr Gastroenterol Rep 2014; 16:386. [PMID: 24659252 DOI: 10.1007/s11894-014-0386-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of esophageal cancer has been increasing while the prognosis remains very poor. Endoscopic submucosal dissection (ESD) was developed in Japan for en bloc resection of early gastric cancer with excellent results. The use of ESD in early squamous cell cancer (SCC) of the esophagus in Japan has been increasing with long-term results comparable to those in early gastric cancer. The use of ESD in Barrett's neoplasia in western countries has been challenged by the low complete resection rates and the risk of metachronous lesions from surrounding non-dysplastic Barrett's epithelium. Efforts to combine ESD with other treatment modalities such as radiofrequency ablation in Barrett's neoplasia and chemoradiation in SCC appear to be promising. The use of steroid therapy (local or systemic) has been demonstrated to prevent post-ESD stenosis, which is the most common complication after esophageal ESD.
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Affiliation(s)
- Hazem Hammad
- Harry S. Truman Memorial Veterans Hospital, University of Missouri Hospital and Clinics, Columbia, MO, USA,
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Takahashi F, Yoshitake N, Akima T, Kino H, Nakano M, Tsuchida C, Tsuchida K, Tominaga K, Sasai T, Masuyama H, Hiraishi H. A second-look endoscopy may not reduce the bleeding after endoscopic submucosal dissection for gastric epithelial neoplasm. BMC Gastroenterol 2014; 14:152. [PMID: 25148855 PMCID: PMC4304014 DOI: 10.1186/1471-230x-14-152] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 08/08/2014] [Indexed: 02/07/2023] Open
Abstract
Background Gastric endoscopic submucosal dissection (ESD) has gradually come to be recommended as the optimal treatment for early gastric cancer; however, one of the primary issues is postoperative bleeding. Although second-look endoscopy is conventionally performed to reduce the risk of postoperative bleeding, its benefit has not yet been clearly elucidated. The objective of this study was to elucidate the benefit of second-look endoscopy. Methods A total of 459 lesions in patients were underwent gastric ESD from May 2004 to April 2013 at our hospital were included in the analysis. The patients were divided into those who had bleeding within 24 hours after ESD (immediate bleeding) and those in whom bleeding occurred 24 hours or more after the procedure (delayed bleeding); the underlying disease, age, lesion site, diameter of the resected specimen, and lesion diameter were analyzed to identify the risk factors for postoperative bleeding after ESD. Results Post-ESD immediate or delayed bleeding occurred in 23 of the 459 cases (5.0%). Second-look endoscopy was performed in 210 of 447 cases (47.0%) excluding 12 cases with immediate bleeding; in the remaining 237 of the 447 cases (53.0%), it was not performed. Post-ESD delayed bleeding occurred in 6 of the 210 cases (2.9%) and 5 of the 237 cases (2.1%), with no statistically significant difference between the two groups. Overall, the following factors were identified as the risk factors for postoperative bleeding: young age (P = 0.005), lesions in the L segment (P = 0.042), and large size of the resected specimen (P = 0.005). The risk factors identified in the immediate bleeding group were lesions in the L segment (P = 0.032), large size of the resected specimen (P < 0.001), and large tumor size (P = 0.011), and those in the delayed bleeding group were young age (P = 0.013) and concomitant renal disease (P = 0.011). Conclusions The results of this study suggest that second-look endoscopy after gastric ESD may not be useful for preventing postoperative bleeding.
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Affiliation(s)
| | - Naoto Yoshitake
- Department of Gastroenterology, Dokkyo Medical University, 880, Kitakobayashi, Mibu, Shimotsuga, Tochigi 321-0293, Japan.
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Komeda Y, Bruno M, Koch A. EMR is not inferior to ESD for early Barrett's and EGJ neoplasia: An extensive review on outcome, recurrence and complication rates. Endosc Int Open 2014; 2:E58-E64. [PMID: 26135261 PMCID: PMC4423274 DOI: 10.1055/s-0034-1365528] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 02/24/2014] [Indexed: 12/21/2022] Open
Abstract
Background and study aims In recent years, it has been reported that early Barrett's and esophagogastric junction (EGJ) neoplasia can be effectively and safely treated using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Multiband mucosectomy (MBM) appears to be the safest EMR method. The aim of this systematic review is to assess the safety and efficacy of MBM compared with ESD for the treatment of early neoplasia in Barrett's or at the EGJ. Methods A literature review of studies published up to May 2013 on EMR and ESD for early Barrett's esophagus (BE) neoplasia and adenocarcinoma at the EGJ was performed through MEDLINE, EMBASE and the Cochrane Library. Results on outcome parameters such as number of curative resections, complications and procedure times are compared and reported. Results A total of 16 studies met the inclusion criteria for analysis in this study. There were no significant differences in recurrence rates when comparing EMR (10/380, 2.6 %) to ESD (1/333, 0.7 %) (OR 8.55; 95 %CI, 0.91 - 80.0, P = 0.06). All recurrences after EMR were treated with additional endoscopic resection. The risks of delayed bleeding, perforation and stricture rates in both groups were similar. The procedure was considerably less time-consuming in the EMR group (mean time 36.7 min, 95 %CI, 34.5 - 38.9) than in the ESD group (mean time 83.3 min, 95 %CI, 57.4 - 109.2). Conclusions The MBM technique for EMR is as effective as ESD when comparing outcomes related to recurrence and complication rates for the treatment of early Barrett's or EGJ neoplasia. The MBM technique is considerably less time-consuming.
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Affiliation(s)
- Yoriaki Komeda
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arjun Koch
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Ryu CB. Expanding indications for ESD: mucosal disease (upper and lower gastrointestinal tract). Gastrointest Endosc Clin N Am 2014; 24:161-7. [PMID: 24679228 DOI: 10.1016/j.giec.2013.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic resection is now considered a curative procedure for early gastric cancer. In Japan, it has increasingly replaced surgical resection for this indication, although in the West it has not been universally accepted as a first-line treatment. Recently, endoscopic submucosal dissection has been increasingly applied to colorectal disease, although it has not become a standard therapeutic procedure for early colorectal carcinoma because of its technical difficulty, the relatively long procedure time required, and the risk of complications, such as perforation and bleeding.
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Affiliation(s)
- Chang Beom Ryu
- Gastroenterology Division, Soonchunhyang University College of Medicine, Digestive Disease Center and Research Institute, Sonnchunhyang University Bucheon Hospital, 1174 Jungdong, Wonmigu, Bucheon, Gyeonggi-do 420-767, South Korea.
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Dumoulin FL, Sido B, Bollmann R, Sauer M. Endoscopic Submucosal Dissection (ESD) in Colorectal Tumors. VISZERALMEDIZIN 2014; 30:39-44. [PMID: 26288580 PMCID: PMC4513806 DOI: 10.1159/000358529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Endoscopic submucosal dissection (ESD) – initially developed for the treatment of early gastric cancer in Japan – is an attractive option for en bloc resection of larger sessile or flat colorectal neoplasia. Methods A review of the current literature on colorectal ESD was carried out. Results In contrast to conventional endoscopic mucosal resection (EMR), ESD for larger colorectal neoplasia yields high en bloc resection rates and very low recurrence rates. The frequency of delayed bleeding is similar for EMR and ESD. Higher perforation rates during ESD are mostly due to microperforations identified and treated during the intervention, and are therefore of minor clinical relevance. A major disadvantage of ESD is the necessity for high-level endoscopic skills and long procedure times. ESD also has the potential to replace laparoscopic surgery or transanal endoscopic microsurgery mainly due to its lower complication rates. Conclusion ESD for the resection of larger flat or sessile colorectal lesions has potential advantages over conventional EMR or minimally invasive surgery. Due to the low incidence of early gastric cancer, experience with ESD will remain limited in Western countries. The spread of colorectal ESD will depend on adequate training opportunities and also on modifications yielding a reduction in procedure time.
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Affiliation(s)
| | - Bernd Sido
- Department of General and Abdominal Surgery, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | | | - Malte Sauer
- Department of Medicine and Gastroenterology, Bonn, Germany
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19
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Chiu PWY. Novel endoscopic therapeutics for early gastric cancer. Clin Gastroenterol Hepatol 2014; 12:120-5. [PMID: 23954641 DOI: 10.1016/j.cgh.2013.07.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/24/2013] [Accepted: 07/30/2013] [Indexed: 02/07/2023]
Abstract
Gastrointestinal cancers are among the commonest cancers worldwide. Treatment of these cancers at an early stage will result in a significantly better prognosis. Endoscopic submucosal dissection (ESD) is a new method of endoscopic resection that can achieve higher rates of en bloc resection for early gastrointestinal neoplasia. Three retrospective case-control studies showed that ESD achieved significantly higher en bloc resection with lower recurrence rates than endoscopic mucosal resection for treatment of early gastric cancers. Most of the reports on clinical outcomes of ESD were from countries with a high incidence of gastric cancers, including Japan and Korea. The development of ESD has been slow for countries outside Japan and Korea because ESD requires a high level of endoscopic skills, and the dissection was performed single-handedly without assistance. A newly developed robotic endoscopic platform will enhance the performance of ESD through the use of 2 robotic arms: one arm for retraction of the mucosa and the other arm for dissection.
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Affiliation(s)
- Philip Wai Yan Chiu
- Department of Surgery, Hong Kong Jockey Club Minimally Invasive Surgical Skills Center, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
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20
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Kanzaki H, Ishihara R, Ohta T, Nagai K, Matsui F, Yamashina T, Hanafusa M, Yamamoto S, Hanaoka N, Takeuchi Y, Higashino K, Uedo N, Iishi H, Tatsuta M. Randomized study of two endo-knives for endoscopic submucosal dissection of esophageal cancer. Am J Gastroenterol 2013; 108:1293-8. [PMID: 23732465 DOI: 10.1038/ajg.2013.161] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 04/23/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Settings for endoscopic submucosal dissection (ESD) of esophageal cancer have not been standardized, and no studies have directly compared ESD devices in humans. METHODS We conducted a randomized study to compare the performances of two different endo-knives, the Flush knife and Mucosectom, for esophageal ESD in 48 lesions. All procedures were initiated by two endoscopists, who were assisted by senior endoscopists with verbal advice. In the Flush-knife group, mucosal incision with a 2-mm Flush knife was followed by submucosal dissection using a 1-mm Flush knife. In the Mucosectom group, mucosal incision with a 2-mm Flush knife was followed by submucosal dissection with a Mucosectom. The primary outcome variable was the procedure time required for submucosal dissection. The secondary outcome variables were total procedure time, self-completion rates, and adverse events. RESULTS Total procedure time in the Mucosectom group was significantly shorter than in the Flush-knife group (57±21 vs. 83±27 min, respectively; P<0.001). The submucosal-dissection time in the Mucosectom group was significantly shorter than in the Flush-knife group (40±18 vs. 61±23 min, respectively; P<0.001). The self-completion rate in the Mucosectom group was slightly higher than in the Flush-knife group, but the difference was not significant (91.7% vs. 75%, respectively; P=0.25). One perforation and one postoperative bleeding occurred in the Flush-knife group, both of which were treated successfully by endoscopic treatment. CONCLUSIONS The Mucosectom reduced the procedure and submucosal-dissection times of esophageal ESD, without increasing adverse events.
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Affiliation(s)
- Hiromitsu Kanzaki
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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21
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Toyonaga T, Man-i M, East JE, Nishino E, Ono W, Hirooka T, Ueda C, Iwata Y, Sugiyama T, Dozaiku T, Hirooka T, Fujita T, Inokuchi H, Azuma T. 1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes. Surg Endosc 2013; 27:1000-1008. [PMID: 23052530 PMCID: PMC3572381 DOI: 10.1007/s00464-012-2555-2] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 08/21/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables en bloc resection of early gastrointestinal neoplasms; however, most ESD articles report small series, with short-term outcomes performed by multiple operators on single organ. We assessed short- and long-term treatment outcomes following ESD for early neoplasms throughout the gastrointestinal tract. METHODS We performed a longitudinal cohort study in single tertiary care referral center. A total of 1,635 early gastrointestinal neoplasms (stomach 1,136; esophagus 138; colorectum 361) were treated by ESD by single operator. Outcomes were complication rates, en bloc R0 resection rates, and long-term overall and disease-specific survival rates at 3 and 5 years for both guideline and expanded criteria for ESD. RESULTS En bloc R0 resection rates were: stomach: 97.1 %; esophagus: 95.7 %; colorectum: 98.3 %. Postoperative bleeding and perforation rates respectively were: stomach: 3.6 and 1.8 %; esophagus: 0 and 0 %; colorectum: 1.7 and 1.9 %. Intra criteria resection rates were: stomach: 84.9 %; esophagus: 81.2 %; colorectum: 88.6 %. Three-year survival rates for lesions meeting Japanese ESD guideline/expanded criteria were for all organ-combined: 93.4/92.7 %. Five-year rates were: stomach: 88.1/84.6 %; esophagus: 81.6/57.3 %; colorectum: 94.3/100 %. Median follow-up period was 53.4 (range, 0.07-98.6) months. Follow-up rate was 94 % (1,020/1,085). There was no recurrence or disease-related death. CONCLUSIONS In this large series by single operator, ESD was associated with high curative resection rates and low complication rates across the gastrointestinal tract. Disease-specific and overall long-term prognosis for patients with lesions within intra criteria after curative resection appeared to be excellent.
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Affiliation(s)
- Takashi Toyonaga
- Department of Endoscopy, Kobe University Hospital, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan.
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22
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Man-i M, Morita Y, Fujita T, East JE, Tanaka S, Wakahara C, Yoshida M, Hayakumo T, Kutsumi H, Inokuchi H, Toyonaga T, Azuma T. Endoscopic submucosal dissection for gastric neoplasm in patients with co-morbidities categorized according to the ASA Physical Status Classification. Gastric Cancer 2013; 16:56-66. [PMID: 22382930 DOI: 10.1007/s10120-012-0145-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Accepted: 01/26/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) has come to be widely performed for reduced invasiveness; however, its safety in patients with co-morbidities is not fully examined. We aimed to evaluate the safety and efficacy of gastric ESD with co-morbidities categorized according to ASA Physical Status Classification. METHODS Two hundred and forty patients of ASA 1 (no co-morbidities), 268 of ASA 2 (mild), and 19 of ASA 3 (severe) were treated by ESD for gastric neoplasms. We retrospectively compared clinicopathological features and treatment results of these three groups. RESULTS Cases (by percent) treated with anticoagulant/platelet agents were more common in the higher ASA grades (ASA 1, 5.8%; ASA 2, 29.1%; ASA 3, 31.6%; P < 0.0001). There were no significant differences in case numbers treated under guideline criteria, curative resection (ASA 1, 79.6%; ASA 2, 79.9%; ASA 3, 78.9%), or complications related to the ESD procedure (e.g., postoperative bleeding, perforation, thermal injury). By a patient risk prediction model on surgery, i.e., P-POSSUM, morbidity was halved, and no patients died compared to a predicted death rate of 0.5-2%; however, total and complications unrelated to ESD procedure (e.g., aspiration pneumonia, ischemic heat attack) were more common in higher ASA grades (ASA 1, ASA 2, ASA 3: 15.4, 23.9, 26.3%, respectively, P = 0.014; 0.4, 7.1, 0%, respectively, P = 0.00087). Deviation rates from clinical pathway were more frequent and hospital stay (days) longer in higher ASA grades (ASA 1, ASA 2, ASA 3: 11.3, 17.9, 26.3%, respectively, P = 0.014; 8, 8, 9%, respectively, P = 0.0053). CONCLUSIONS ESD is an efficient treatment for gastric neoplasms with co-morbidities. However, additional caution is required because co-morbidity is a risk factor for both total complications and complications unrelated to the ESD procedure, and may cause deviations in the clinical course and prolonged hospital stay.
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Affiliation(s)
- Mariko Man-i
- Department of Gastroenterology, Kobe University, Kobe, Japan.
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Fukuzawa M, Gotoda T. History of endoscopic submucosal dissection and role for colorectal endoscopic submucosal dissection: A Japanese perspective. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Toyonaga T, Nishino E, Man-i M, East JE, Azuma T. Principles of quality controlled endoscopic submucosal dissection with appropriate dissection level and high quality resected specimen. Clin Endosc 2012; 45:362-374. [PMID: 23251883 PMCID: PMC3521937 DOI: 10.5946/ce.2012.45.4.362] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/24/2012] [Accepted: 09/04/2012] [Indexed: 12/13/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) has enabled en bloc resection of early stage gastrointestinal tumors with negligible risk of lymph node metastasis, regardless of tumor size, location, and shape. However, ESD is a relatively difficult technique compared with conventional endoscopic mucosal resection, requiring a longer procedure time and potentially causing more complications. For safe and reproducible procedure of ESD, the appropriate dissection of the ramified vascular network in the level of middle submucosal layer is required to reach the avascular stratum just above the muscle layer. The horizontal approach to maintain the appropriate depth for dissection beneath the vascular network enables treatment of difficult cases with large vessels and severe fibrosis. The most important aspect of ESD is the precise evaluation of curability. This approach can also secure the quality of the resected specimen with enough depth of the submucosal layer.
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Affiliation(s)
| | - Eisei Nishino
- Department of Pathology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Mariko Man-i
- Frontier Medical Science in Gastroenterology, Kobe University School of Medicine, Kobe, Japan
| | - James E. East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Takeshi Azuma
- Frontier Medical Science in Gastroenterology, Kobe University School of Medicine, Kobe, Japan
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Yamashina T, Ishihara R, Uedo N, Nagai K, Matsui F, Kawada N, Oota T, Kanzaki H, Hanafusa M, Yamamoto S, Hanaoka N, Takeuchi Y, Higashino K, Iishi H. Safety and curative ability of endoscopic submucosal dissection for superficial esophageal cancers at least 50 mm in diameter. Dig Endosc 2012; 24:220-5. [PMID: 22725105 DOI: 10.1111/j.1443-1661.2011.01215.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Limited data are available regarding the use of endoscopic submucosal dissection (ESD) for superficial esophageal cancers ≥ 50 mm in diameter. The aim of the present study was to investigate the safety and success of ESD for superficial esophageal cancers ≥ 50 mm. METHODS A total of 39 patients with superficial esophageal squamous cell carcinoma ≥ 50 mm were treated with ESD at Osaka Medical Center for Cancer and Cardiovascular Diseases between January 2004 and April 2011, and were analyzed in a retrospective study. RESULTS En bloc resection was achieved in all patients. One mediastinal emphysema without perforation occurred during the procedure. Stricture developed in 11 of 39 patients, requiring a median of five endoscopic balloon dilatation procedures. Thirty-three clinical epithelial or lamina propria mucosal cancers were treated by ESD with curative intent, of which invasion into the muscularis mucosa or deeper was detected in seven and lymphovascular involvement in three. The en bloc resection rate was 100% with a tumor-free margin achieved in 92% of lesions. The curative resection and complication rates during ESD were 70% and 2.5%, respectively. CONCLUSION ESD achieved a high en bloc resection rate of 92% with a tumor-free margin. Curative resection rate of ESD in patients with clinical epithelial or lamina propria mucosal cancers was not low at 70%. However, the risk of stricture must be taken into account when considering the use of ESD in lesions ≥ 50 mm.
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Affiliation(s)
- Takeshi Yamashina
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Sakurazawa N, Kato S, Fujita I, Kanazawa Y, Onodera H, Uchida E. Supportive techniques and devices for endoscopic submucosal dissection of gastric cancer. World J Gastrointest Endosc 2012; 4:231-5. [PMID: 22720124 PMCID: PMC3377865 DOI: 10.4253/wjge.v4.i6.231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 02/26/2012] [Accepted: 05/27/2012] [Indexed: 02/05/2023] Open
Abstract
The indications for endoscopic treatment have expanded in recent years, and relatively intestinal-type mucosal stomach carcinomas with a low potential for metastasis are now often resected en bloc by endoscopic submucosal dissection (ESD), even if they measure over 20 mm in size. However, ESD requires complex maneuvers, which entails a long operation time, and is often accompanied by complications such as bleeding and perforation. Many technical developments have been implemented to overcome these complications. The scope, cutting device, hemostasis device, and other supportive devices have been improved. However, even with these innovations, ESD remains a potentially complex procedure. One of the major difficulties is poor visualization of the submucosal layer resulting from the poor countertraction afforded during submucosal dissection. Recently, countertraction devices have been developed. In this paper, we introduce countertraction techniques and devices mainly for gastric cancer.
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Affiliation(s)
- Nobuyuki Sakurazawa
- Nobuyuki Sakurazawa, Shunji Kato, Itsuo Fujita, Yoshikazu Kanazawa, Hiroyuki Onodera, Eiji Uchida, Department of Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan
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27
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Homma K, Otaki Y, Sugawara M, Kobayashi M. Efficacy of novel SB knife Jr examined in a multicenter study on colorectal endoscopic submucosal dissection. Dig Endosc 2012; 24 Suppl 1:117-20. [PMID: 22533765 DOI: 10.1111/j.1443-1661.2012.01266.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Secure manipulation of forceps in endoscopic submucosal dissection (ESD) for colorectal tumors is sometimes hindered by the characteristics of that organ. SB knife Jr, which are scissor forceps using a mono-pole high frequency, were developed to avoid the difficulty of ESD operation in the colorectum. The aim of the present study was to examine the effectiveness of the SB knife Jr in colorectal ESD in 11 hospitals, mostly in northeastern Japan. MATERIALS One hundred and two colorectal tumors (49 non-granular laterally spreading tumor [LST] lesions, 39 granular LST lesions and 14 other lesions) that were resected by ESD operations using SB knife Jr between October 2009 and March 2010. RESULTS All tumors (102/102) were resected en bloc and could be observed in detail. The mean size of the resected pieces was 40.3 mm. The mean operation time was 54.2 min. Of the complications, one case of micro-perforation occurred during the manipulation of submucosal dissection, and this case was treated with clips in that operation. The rates of resection carried out only with SB knife Jr were 74.5% (76/102). CONCLUSION The novel ESD using SB knife Jr in the colorectum offers a breakthrough in resection techniques for not only expert endoscopists but also general endoscopists.
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Affiliation(s)
- Kiyoaki Homma
- Department of Therapeutic Endoscopy, Nihonkai General Hospital, Yamagata, Japan.
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Honda K, Akiho H. Endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. World J Gastrointest Pathophysiol 2012; 3:44-50. [PMID: 22532931 PMCID: PMC3334390 DOI: 10.4291/wjgp.v3.i2.44] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/31/2012] [Accepted: 04/10/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic resection is an effective treatment for non-invasive esophageal squamous cell neoplasms (ESCNs). Endoscopic mucosal resection (EMR) has been developed for small localized ESCNs as an alternative to surgical therapy because it shows similar effectiveness and is less invasive than esophagectomy. However, EMR is limited in resection size and therefore piecemeal resection is performed for large lesions, resulting in an imprecise histological evaluation and a high frequency of local recurrence. Endoscopic submucosal dissection (ESD) has been developed in Japan as one of the standard endoscopic resection techniques for ESCNs. ESD enables esophageal lesions, regardless of their size, to be removed en bloc and thus has a lower local recurrence rate than EMR. The development of new devices and the establishment of optimal strategies for esophageal ESD have resulted in fewer complications such as perforation than expected. However, esophageal stricture after ESD may occur when the resected area is larger than three-quarters of the esophageal lumen or particularly when it encompasses the entire circumference; such a stricture requires multiple sessions of endoscopic balloon dilatation. Recently, oral prednisolone has been reported to be useful in preventing post-ESD stricture. In addition, a combination of chemoradiotherapy (CRT) and ESD might be an alternative therapy for submucosal esophageal cancer that has a risk of lymph node metastasis because esophagectomy is extremely invasive; CRT has a higher local recurrence rate than esophagectomy but is less invasive. ESD is likely to play a central role in the treatment of superficial esophageal squamous cell neoplasms in the future.
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Muraki Y, Enomoto S, Iguchi M, Niwa T, Maekita T, Yoshida T, Moribata K, Shingaki N, Deguchi H, Ueda K, Inoue I, Tamai H, Kato J, Fujishiro M, Ichinose M. Diazepam during endoscopic submucosal dissection of gastric epithelial neoplasias. World J Gastrointest Endosc 2012; 4:80-6. [PMID: 22442745 PMCID: PMC3309897 DOI: 10.4253/wjge.v4.i3.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 01/17/2012] [Accepted: 03/02/2012] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate risk factors and adverse events related to high-dose diazepam administration during endoscopic submucosal dissection for gastric neoplasias.
METHODS: Between February 2002 and December 2009, a total of 286 patients with gastric epithelial neoplasia underwent endoscopic submucosal dissection in our hospital. To achieve moderate sedation, 5-7.5 mg of diazepam was administered intravenously by non-anesthesiologists. Intermittent additional administration of 2.5-5 mg diazepam was performed if uncontrollable body movement of the patient was observed. All patients were classified into groups based on the required diazepam dose: low-dose (≤ 17.5 mg, n = 252) and high-dose (> 17.5 mg, n = 79).
RESULTS: Differences between the low- and high-dose diazepam groups were observed in lifetime alcohol consumption (0.30 ± 0.48 vs 0.44 ± 0.52 tons, P = 0.032), body weight (58.4 ± 10.3 vs 62.0 ± 9.9 kg, P = 0.006), tumor size (15 ± 10 vs 23 ± 18 mm, P < 0.001), lesion location (P < 0.001) and the presence of ulcerative findings (14/238 vs 18/61, P < 0.001). Multivariate analysis identified all five variables as independently related to required diazepam dosage. In terms of adverse reactions to diazepam administration, paradoxical excitement was significantly more frequent in the high-dose diazepam group (P < 0.001).
CONCLUSION: Intermittent administration of diazepam enabled safe completion of gastric endoscopic submucosal dissection except in patients who were alcohol abusers or obese, or who showed complicated lesions.
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Affiliation(s)
- Yosuke Muraki
- Yosuke Muraki, Shotaro Enomoto, Mikitaka Iguchi, Toru Niwa, Takao Maekita, Takeichi Yoshida, Kosaku Moribata, Naoki Shingaki, Hisanobu Deguchi, Kazuki Ueda, Izumi Inoue, Hideyuki Tamai, Jun Kato, Masao Ichinose, Second Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama 641-0012, Japan
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30
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Ryu CB, Chen YK. Endoscopic Therapy for Gastric Neoplasms. CLINICAL GASTROINTESTINAL ENDOSCOPY 2012:425-447. [DOI: 10.1016/b978-1-4377-1529-3.00033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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31
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Kim SG. Endoscopic treatment for early gastric cancer. J Gastric Cancer 2011; 11:146-54. [PMID: 22076219 PMCID: PMC3204472 DOI: 10.5230/jgc.2011.11.3.146] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 08/20/2011] [Accepted: 08/22/2011] [Indexed: 01/03/2023] Open
Abstract
Endoscopic resection has been accepted as a curative modality for early gastric cancer (EGC). Since conventional endoscopic mucosal resection (EMR) has been introduced, many improvements in endoscopic accessories and techniques have been achieved. Recently, endoscopic submucosal dissection (ESD) using various electrosurgical knives has been performed for complete resection of EGC and enables complete resection of EGC, which is difficult to completely resect in the era of conventional EMR. Currently, ESD is accepted as the standard method for endoscopic resection of EGC in indicated cases. In this review, the history of endoscopic treatment for EGC, overall ESD procedures, and indications and clinical results of endoscopic treatment will be presented.
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Affiliation(s)
- Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Toyonaga T, Man-i M, Fujita T, East JE, Coumaros D, Morita Y, Yoshida M, Hayakumo T, Inokuchi H, Azuma T. Endoscopic submucosal dissection using the Flush knife and the Flush knife BT. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011; 13:84-90. [DOI: 10.1016/j.tgie.2011.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Toyonaga T, Man-I M, Fujita T, Nishino E, Ono W, Morita Y, Sanuki T, Masuda A, Yoshida M, Kutsumi H, Inokuchi H, Azuma T. The performance of a novel ball-tipped Flush knife for endoscopic submucosal dissection: a case-control study. Aliment Pharmacol Ther 2010; 32:908-915. [PMID: 20839389 DOI: 10.1111/j.1365-2036.2010.04425.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) using short needle knives is safe and effective, but bleeding is a problem due to low haemostatic capability. AIM To assess the performance of a novel ball-tipped needle knife (Flush knife-BT) for ESD with particular emphasis on haemostasis. METHODS A case-control study to compare the performance for ESD of 30 pairs of consecutive early gastrointestinal lesions (oesophagus: 12, stomach: 32, colorectum: 16) with standard Flush knife (F) vs. Flush knife-BT (BT). Primary outcome was efficacy of intraprocedure haemostasis. Secondary outcomes included procedure time, procedure speed (dividing procedure time into the area of resected specimen), en bloc resection rate and recurrence rate. RESULTS Median intraoperative bleeding points and bleeding points requiring haemostatic forceps were smaller in the BT group than in the F group (4 vs. 8, P < 0.0001, 0 vs. 3, P < 0.0001). There was no difference between groups for procedure time; however, procedure speed was shorter in the BT group (P = 0.0078). En bloc and en bloc R0 resection rates were 100%, with no perforation or post-operative bleeding. No recurrence was observed in either group at follow-up 1 year postprocedure. CONCLUSIONS Ball-tipped Flush knife (Flush knife-BT) appears to improve haemostatic efficacy and dissection speed compared with standard Flush knife.
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Affiliation(s)
- T Toyonaga
- Department of Endoscopy, Kobe University Hospital, Japan.
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Goto O, Fujishiro M, Kodashima S, Ono S, Niimi K, Hirano K, Yamamichi N, Koike K. A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding. Gastrointest Endosc 2010; 71:241-248. [PMID: 19922919 DOI: 10.1016/j.gie.2009.08.030] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 08/27/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is one of the curative endoluminal surgical procedures for gastric epithelial neoplasms. There has been little research on bleeding after gastric ESD. OBJECTIVE To investigate cases of post-ESD bleeding and to verify whether a second-look endoscopy after ESD is effective in the prevention of delayed bleeding. DESIGN A retrospective study with consecutive data. SETTING A single tertiary referral center. SUBJECTS A total of 454 gastric epithelial neoplasms (386 early gastric cancers and 68 gastric adenomas). INTERVENTIONS ESD and second-look endoscopy. MAIN OUTCOME MEASUREMENTS Predictors on post-ESD bleeding by univariate analysis, incidence of post-ESD bleedings, and the timing of those before and after second-look endoscopy. RESULTS Post-ESD bleeding occurred in 26 (5.7%) lesions. Gross type (flat or depressed type) was the only factor influencing post-ESD bleeding. All cases of post-ESD bleeding occurred within 14 days after ESD (median 2; range 0-14), and bleeding tended to occur from the lower and upper stomach earlier and later, respectively. In 19 lesions with delayed bleeding more than 24 hours after ESD, the maximum delayed bleeding rates before and after the second-look endoscopy were 2.8% and 2.5%, respectively. LIMITATIONS A retrospective, single-center analysis. CONCLUSIONS A second-look endoscopy after gastric ESD may contribute little to the prevention of delayed bleeding.
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Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
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Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2009; 24:343-52. [PMID: 19517168 DOI: 10.1007/s00464-009-0562-8] [Citation(s) in RCA: 428] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 04/17/2009] [Accepted: 05/14/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) has recently been applied to the treatment of superficial colorectal cancer. Clinical outcomes compared with conventional endoscopic mucosal resection (EMR) have not been determined so our aim was to compare the effectiveness of ESD with conventional EMR for colorectal tumors >or=20 mm. METHODS This was a retrospective case-controlled study performed at the National Cancer Center Hospital in Tokyo, Japan involving 373 colorectal tumors >or=20 mm determined histologically to be curative resections. Data acquisition was from a prospectively completed database. We evaluated histology, tumor size, procedure time, en bloc resection rate, recurrence rate, and associated complications for both the ESD and EMR groups. RESULTS A total of 145 colorectal tumors were treated by ESD and another 228 were treated by EMR. ESD was associated with a longer procedure time (108 +/- 71 min/29 +/- 25 min; p < 0.0001), higher en bloc resection rate (84%/33%; p < 0.0001) and larger resected specimens (37 +/- 14 mm/28 +/- 8 mm; p = 0.0006), but involved a similar percentage of cancers (69%/66%; p = NS). There were three (2%) recurrences in the ESD group and 33 (14%) in the EMR group requiring additional EMR (p < 0.0001). The perforation rate was 6.2% (9) in the ESD group and 1.3% (3) in the EMR group (p = NS) with delayed bleeding occurring in 1.4% (2) and 3.1% (7) of the procedures (p = NS), respectively, as all complications were effectively treated endoscopically. CONCLUSIONS Despite its longer procedure time and higher perforation rate, ESD resulted in higher en bloc resection and curative rates compared with EMR and all ESD perforations were successfully managed by conservative endoscopic treatment.
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Goto O, Fujishiro M, Kodashima S, Ono S, Omata M. Is it possible to predict the procedural time of endoscopic submucosal dissection for early gastric cancer? J Gastroenterol Hepatol 2009; 24:379-383. [PMID: 19054263 DOI: 10.1111/j.1440-1746.2008.05675.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD) has been expected to be a possible curative treatment, especially for node-negative early gastric cancer (EGC). We investigated the influential factors on the procedural time of gastric ESD with a Flex knife for the estimation. METHODS In 222 intestinal-type EGC resected by ESD experts with established techniques, age, sex, location, circumference, gross type, tumor size, tumor depth, ulcerative findings, the period of ESD, the operator, and the experience of the operator were retrospectively analyzed. Predictors with a significant difference, as determined by multivariate analysis, were used to compose a predictive formula of procedural time. RESULTS Location, gross type, tumor depth, ulcerative findings, and tumor size were considered influential factors on the procedural time by univariate analysis. Location in the upper-third of the stomach, presence of ulcerative findings, and > 20 mm in size were independent factors, as determined by multivariate analysis. Procedural time (min) was nearly equal to the maximal tumor size (mm) multiplied by 2.5, and an additional 40 min was required if the tumor was located in the upper-third of the stomach or had ulcerative findings (in both situations, an additional 80 min was needed). CONCLUSION The procedural time of ESD with a Flex knife for EGC can be predicted by tumor size, location, and existence of ulcerative findings. The estimation of procedural time may be very useful to determine the operation schedule.
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Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
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Hirasaki S, Kozu T, Yamamoto H, Sano Y, Yahagi N, Oyama T, Shimoda T, Sugano K, Tajiri H, Takekoshi T, Saito D. Usefulness and safety of 0.4% sodium hyaluronate solution as a submucosal fluid "cushion" for endoscopic resection of colorectal mucosal neoplasms: a prospective multi-center open-label trial. BMC Gastroenterol 2009; 9:1. [PMID: 19128517 PMCID: PMC2651182 DOI: 10.1186/1471-230x-9-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 01/08/2009] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sodium hyaluronate (SH) solution has been used for submucosal injection in endoscopic resection to create a long-lasting submucosal fluid "cushion". Recently, we proved the usefulness and safety of 0.4% SH solution in endoscopic resection for gastric mucosal tumors. To evaluate the usefulness of 0.4% SH as a submucosal injection solution for colorectal endoscopic resection, we conducted an open-label clinical trial on six referral hospitals in Japan. METHODS A prospective multi-center open-label study was designed. A total of 41 patients with 5-20 mm neoplastic lesions localized in the colorectal mucosa at six referral hospitals in Japan in a single year period from December 2002 to November 2003 were enrolled and underwent endoscopic resection with SH. The usefulness of 0.4% SH was assessed by the en bloc complete resection and the formation and maintenance of mucosal lesion-lifting during endoscopic resection. Safety was evaluated by analyzing adverse events during the study period. RESULTS The usefulness rate was high (82.5%; 33/40). The following secondary outcome measures were noted: 1) steepness of mucosal lesion-lifting, 75.0% (30/40); 2) intraoperative complications, 10.0% (4/40); 3) time required for mucosal resection, 6.7 min; 4) volume of submucosal injection, 6.8 mL and 5) ease of mucosal resection, 87.5% (35/40). Two adverse events of bleeding potentially related to 0.4% SH were reported. CONCLUSION Using 0.4% SH solution enabled sufficient lifting of a colorectal intramucosal lesion during endoscopic resection, reducing the need for additional injections and the risk of perforation. Therefore, 0.4% SH may contribute to the reduction of complications and serve as a promising submucosal injection solution due to its potentially superior safety in comparison to normal saline solution.
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Affiliation(s)
- Shoji Hirasaki
- Department of Internal Medicine, Sumitomo Besshi Hospital, Ehime, Japan
| | - Takahiro Kozu
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hironori Yamamoto
- Department of Internal medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Yasushi Sano
- Division of Digestive Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Naohisa Yahagi
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Tsuneo Oyama
- Department of Gastroenterology, Saku General Hospital, Nagano, Japan
| | - Tadakazu Shimoda
- Clinical Laboratory Division, National Cancer Center Hospital, Tokyo, Japan
| | - Kentaro Sugano
- Department of Internal medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hisao Tajiri
- Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Takekoshi
- Department of Gastroenterology, Maeda Hospital, Tokyo, Japan
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Goto O, Fujishiro M, Kodashima S, Kakushima N, Ono S, Yahagi N, Omata M. Feasibility of electrocautery snaring as the final step of endoscopic submucosal dissection for stomach epithelial neoplasms. Dig Liver Dis 2009; 41:26-30. [PMID: 18394978 DOI: 10.1016/j.dld.2008.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 01/16/2008] [Accepted: 02/18/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a novel endoluminal technique that permits the resection of gastric neoplasms. AIM To analyse the feasibility of snaring as the final step of ESD. PATIENTS AND METHODS One hundred and ninety-nine consecutive gastric neoplasms resected by four ESD experts from January 2004 to May 2007 were investigated. Forty-five (22.6%) were finally resected finally using a snare. Rates of en bloc resection, complete (R0 plus en bloc) resection, mean operation time, and complications were assessed between the snaring and the non-snaring groups. RESULTS En bloc resection rate was significantly lower and delayed bleeding rate was significantly higher in the snaring group than in the non-snaring group (91.1% [41/45] vs. 100% [154/154], 11.1% [5/45] vs. 1.9% [3/154], respectively), although complete resection rate (86.7% [39/45] vs. 92.9% [143/154]) and mean operation time (70.2 min vs. 75.8 min) were not significantly different between the two groups. Six perforation cases (3 [6.7%] in the snaring group, 3 [1.9%] in the non-snaring group) were observed, but snaring did not lead to perforation in any case. When the subjects were divided into small (< or = 2 cm) and large (> 2 cm) tumours, en bloc resection rate in large tumours was still significantly different between the groups (76.9% [10/13] vs. 100% [67/67]), whereas in small tumours it was no longer significantly different (96.9% [31/32] vs. 100% [87/87]). CONCLUSIONS Snaring may facilitate successful ESD for smaller tumours, but multiple-piece resection should be taken into account especially for larger tumours.
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Affiliation(s)
- O Goto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Kim SG. Endoscopic Resection of Early Gastric Cancer. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2009; 54:77-82. [DOI: 10.4166/kjg.2009.54.2.77] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Pouw RE, Bergman JJGHM. Endoscopic resection of early oesophageal and gastric neoplasia. Best Pract Res Clin Gastroenterol 2008; 22:929-43. [PMID: 18790439 DOI: 10.1016/j.bpg.2008.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In the last decades, endoscopic treatment of early neoplastic lesions in the oesophagus and stomach has evolved as a valid and less invasive alternative to surgical resection. Endoscopic resection (ER) is the cornerstone of endoscopic therapy. Apart from the curative potential of ER, by removing neoplastic lesions, ER may also serve as a diagnostic tool. The relatively large tissue specimens obtained with ER enable accurate histological staging of a lesion, allowing for optimal decision making for further patient management. ER was pioneered in Japan, mainly for the resection of gastric lesions and squamous oesophageal neoplasia, and also Western countries have been increasingly implementing ER in the treatment of early gastro-oesophageal neoplasia, mostly associated with Barrett oesophagus. In this review we will give an overview of the different techniques that have been developed and modified for ER of early gastro-oesophageal neoplasia, and we will discuss the indications for ER in the oesophagus and stomach.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Iizuka T, Kikuchi D, Hoteya S, Yahagi N. The acetic acid + indigocarmine method in the delineation of gastric cancer. J Gastroenterol Hepatol 2008; 23:1358-61. [PMID: 18853994 DOI: 10.1111/j.1440-1746.2008.05528.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM For the purpose of precise preoperative diagnosis that ensures complete endoscopic resection, it is important to accurately determine the lateral spread of gastric cancer lesions. The acetic acid + indigocarmine (AI) method used by us has been found to meet this need. This paper reports its usefulness in the determination of lateral spread of gastric cancer before endoscopic submucosal dissection (ESD). METHODS The present study was conducted in 114 patients who were operated on for an early-stage gastric cancer, after determining the lateral spread of cancerous lesions by the AI method, between September 2005 and December 2006. The negative lateral stump reaction rate obtained in ESD was conducted in areas delineated by the AI method. The borderline clarification rate obtained by the AI method and the indigocarmine (I) method were compared between the lesions with and without clear borders under observation with the naked eye. RESULTS The lateral stump after ESD conducted using the AI method was histologically negative in 111 of the 114 patients (97%). The lesion spread was clarified by the AI method in 103 patients (90%): 55 (95%) and 48 (86%) patients with and without clear macroscopic lesion borders, respectively. Compared to the I method, the AI method clarified the lesion spread in a significantly higher percentage of patients with macroscopically unclear lesion borders (P = 0.015). CONCLUSION The present study stresses that the AI method should be used to conduct ESD more safely and accurately in patients with well or moderately differentiated adenocarcinoma.
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Affiliation(s)
- Toshiro Iizuka
- Department of Gastroenterology, Toranomon Hospital, Toranomon, Tokyo, Japan.
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Yamamoto H, Yahagi N, Oyama T, Gotoda T, Doi T, Hirasaki S, Shimoda T, Sugano K, Tajiri H, Takekoshi T, Saito D. Usefulness and safety of 0.4% sodium hyaluronate solution as a submucosal fluid "cushion" in endoscopic resection for gastric neoplasms: a prospective multicenter trial. Gastrointest Endosc 2008; 67:830-9. [PMID: 18155216 DOI: 10.1016/j.gie.2007.07.039] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 07/23/2007] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sodium hyaluronate (SH) solution has been used for submucosal injection in endoscopic resection to create a long-lasting submucosal fluid "cushion." OBJECTIVES Our purpose was to assess the usefulness and safety of 0.4% SH solution in endoscopic resection. DESIGN A prospective multicenter randomized controlled trial. SETTING Six referral hospitals in Japan. PATIENTS One hundred forty patients with 5- to 20-mm gastric intramucosal neoplastic lesions. INTERVENTIONS Patients were randomized into 0.4% SH and control groups. Endoscopic resection was performed with 0.4% SH or normal saline solution for submucosal injection. PRIMARY OUTCOME MEASURE The usefulness of 0.4% SH solution was assessed by en bloc complete resection and the formation and maintenance of mucosal lesion-lifting during endoscopic resection. SECONDARY OUTCOME MEASURES (1) steepness of mucosal lesion lifting, (2) complications, (3) time required for mucosal resection, (4) volume of submucosal injection solution, and (5) ease of mucosal resection. Safety was assessed by analyzing adverse events during the study period. RESULTS The usefulness rate was significantly higher for the 0.4% SH group (88.4%, 61/69) than for the control group (58.6%, 41/70). As secondary outcome measures, significant intergroup differences (P < .001) were noted for (1) steepness of mucosal lesion lifting, (2) volume of submucosal injection solution, and (3) ease of mucosal resection. No serious adverse events were encountered in either group. LIMITATIONS Lack of blinding. Safety was not a powered outcome measure. CONCLUSIONS Using 0.4% SH as a submucosal injection solution in endoscopic resection enabled the formation and maintenance of sufficient mucosal lesion lifting for gastric intramucosal lesions, reducing the need for additional injections and simplifying mucosal resection. Use of 0.4% SH thus simplifies the complicated procedures involved in endoscopic resection.
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Affiliation(s)
- Hironori Yamamoto
- Current affiliations: Department of Internal Medicine, Division of Gastroenterology, Jichi Medical School, Tochigi, Japan
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Poppers DM, Haber GB. Endoscopic mucosal resection of colonic lesions: current applications and future prospects. Med Clin North Am 2008; 92:687-705, x. [PMID: 18387382 DOI: 10.1016/j.mcna.2008.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The introduction of submucosal fluid injection has remarkably extended the range of endoscopically resectable polyps. The limiting factor for endoscopic resection is not polyp size, but polyp depth. Endoscopic ultrasound is a useful adjunctive diagnostic tool to assess the depth of invasion. The success of are section ultimately depends on pathologic confirmation of a benign nature of this lesion or of a cancer limited to the mucosa. Selected well-differentiated cancers without lymphovascular invasion of the superficial submucosa can be successfully resected endoscopically.
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Affiliation(s)
- David M Poppers
- Division of Gastroenterology, Center for Advanced Therapeutic Endoscopy, Lenox Hill Hospital, 6 Black Hall, 100 East 77th Street, New York, NY 10021, USA
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Goto O, Fujishiro M, Kakushima N, Kodashima S, Ono S, Yamaguchi H, Nomura S, Kaminishi M, Omata M. Endoscopic submucosal dissection as a staging measure may not lead to worse prognosis in early gastric cancer patients with additional gastrectomy. Dig Liver Dis 2008; 40:293-297. [PMID: 18191627 DOI: 10.1016/j.dld.2007.11.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 11/21/2007] [Accepted: 11/21/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection is a novel endoluminal technique that enables resection of early stage gastrointestinal malignancies in an en bloc fashion. AIM To assess whether preceding endoscopic submucosal dissection affected the prognoses of patients who underwent additional gastrectomy with lymph node dissection due to suspicion of nodal metastasis from endoscopic submucosal dissection specimens. PATIENTS AND METHODS Thirty-one patients with early gastric cancer who underwent gastrectomy after endoscopic submucosal dissection were retrospectively investigated in terms of their survival and tumour recurrence. Additional gastrectomy was performed when histology of the endoscopic submucosal dissection specimens revealed that the tumours did not meet the criteria for node-negative cancers. RESULTS Twenty-three (74%) and eight (26%) patients had undergone endoscopic submucosal dissection previously due to clinical diagnoses of node-negative cancers and possible node-positive cancers, respectively. Histology of the resected stomachs and lymph nodes revealed residual carcinoma of the stomach in two (6.5%) patients and nodal metastases in four (13%) patients. All patients remain alive without recurrence (median follow-up, 3.4 years; range, 0.6-5.2 years). CONCLUSIONS Based on the histology of endoscopic submucosal dissection specimens, preceding endoscopic submucosal dissection itself had no negative influence on a patient's prognosis when additional gastrectomy was performed. It may be permissible to resect some early gastric cancers by endoscopic submucosal dissection as a first step to prevent unnecessary gastrectomy, if technically resectable.
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Affiliation(s)
- O Goto
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
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Kawano T, Haruki S, Ogiya K, Kawada K, Nakajima Y, Nishikage T, Kojima K, Nagai K, Kawachi H. Reliability of endoscopic esophageal mucosectomy using TxHood, a multipurpose treatment hood. Surg Endosc 2008; 22:2466-9. [PMID: 18270776 DOI: 10.1007/s00464-008-9742-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 08/27/2007] [Accepted: 11/28/2007] [Indexed: 12/15/2022]
Abstract
Endoscopic mucosectomy, comprising both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), is a minimally invasive treatment for patients with early esophageal carcinoma. The use of ESD is appropriate for mucosal lesions of any size. However, ESD techniques are relatively difficult and can lead to serious complications such as perforation and massive bleeding, which have been reported more frequently after ESD than after EMR. This study describes a novel technique for ESD using a newly designed multipurpose treatment hood (TxHood) as well as basic experiments to ensure its safety. The TxHood includes various therapeutic tools such as an electric needleknife, a snare wire, and an injection needle, and the lines can be selected freely before insertion of an enodoscope covered by a TxHood. The main techniques for ESD are endoscopic submucosal saline injections on demand through a working channel of the endoscope or TxHood and a cut or swing cut with a needleknife attached to the TxHood. Moreover, the target area can be grasped with a grasping forceps through a working channel of the endoscope to obtain effective countertraction. In these experiments, an electric needleknife set parallel to the shaft of the endoscope offered safety and ease of handling for the dissecting procedures. Altogether, 16 resections of mucosa with an average size of 3.5 x 2.5 cm (range, 2 x 2 to 7 x 4 cm) were performed. The average time required for each targeted endoscopic resection area was about 15 min. No perforations or instances of uncontrollable bleeding occurred. In conclusion, this basic study demonstrates that the new ESD technique with the TxHood provides a useful treatment for early esophageal carcinoma and may be applicable for all mucosal or submucosal tumors in the gastrointestinal tract.
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Affiliation(s)
- T Kawano
- Department of Surgery, Tokyo Medical and Dental University Hospital, Yushima 1-5-45, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Shastri YM, Kriener S, Caspary WF, Schneider A. Autologous blood as a submucosal fluid cushion for endoscopic mucosal therapies: results of an ex vivo study. Scand J Gastroenterol 2007; 42:1369-75. [PMID: 17852858 DOI: 10.1080/00365520701420743] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Submucosal injection of fluid is used to elevate lesions in order to prevent perforation, which is the most calamitous complication during endoscopic resection therapies. There are several injection options when performing mucosal elevation (normal saline (NS), sodium hyaluronate (SH), etc.). Submucosal injection of fresh, autologous blood offers some advantages because of its specific properties: corpuscular components ensure prolonged elevation and procoagulatory constituents prevent post-interventional bleeding. The purpose of this study was to compare the ex vivo performance of autologous blood as a submucosal fluid cushion (SFC) with that of NS, SH and DW (dextrose water). MATERIAL AND METHODS The proximal third of a resected porcine stomach was cut into squares. One millilitre NS, DW, SH and fresh porcine blood was injected into the submucosa. The height and duration of the submucosal injections were objectively measured during 1 h. Mucosal elevations were resected using an electro snare. RESULTS The initial height and width of the mucosal elevations were comparable for SH and blood, and significantly higher compared with NS and DW. Mucosal elevation after injecting autologous blood persisted significantly longer compared with NS (p <0.05), but did not differ from hyaluronate. Histopathological examination of the resected specimen confirmed the appropriate submucosal injection of these substances. CONCLUSIONS Submucosal injection of autologous blood with a standard endoscopic injection needle is possible and generates adequate mucosal elevation for the resection of high-quality specimens. This procedure could offer a "gratis" option for SFC as opposed to the expensive SH. Further clinical studies are needed to substantiate its use.
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Affiliation(s)
- Yogesh M Shastri
- Department of Medicine I, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany.
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Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, Kikuchi T, Fu KI, Sano Y, Saito D. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 2007; 66:966-73. [PMID: 17524403 DOI: 10.1016/j.gie.2007.02.053] [Citation(s) in RCA: 291] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Accepted: 02/27/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer; however, it is not widely used in the colorectum because of its technical difficulty. OBJECTIVE To determine the feasibility of using ESD for treating large superficial colorectal tumors and to evaluate the clinical outcome. DESIGN AND SETTING Case series conducted at the National Cancer Center Hospital in Tokyo. PATIENTS A total of 198 consecutive patients were treated for 200 lesions. INTERVENTIONS Procedures were performed, before July 2004, by using a monopolar needle knife or an insulation-tipped knife (IT knife). After July 2004, the procedures were performed by using a bipolar needle knife or an IT knife. After injection of glycerol and sodium hyaluronate acid into the submucosal (sm) layer, a circumferential incision was made and sm dissection was performed endoscopically. MAIN OUTCOME MEASUREMENTS The en bloc resection rate was 84% and the curative resection rate was 83%. RESULTS Among the 200 ESDs, 51 involved tubular adenomas, 99 intramucosal cancers, 22 minute sm cancers, and 28 sm deep cancers. The median operation time was 90 minutes, and the mean size of resected specimens was 38 mm (range, 20-150 mm). Perforations occurred in 10 cases (5%) and postoperative bleeding in 4 cases (2%), but only 1 perforation case needed emergency surgery, because endoscopic clipping was ineffective. LIMITATIONS No long-term outcome data yet. CONCLUSIONS ESD is a feasible technique for treating large superficial colorectal tumors, because it provides a higher en bloc resection rate and is less invasive than surgical resection.
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Affiliation(s)
- Yutaka Saito
- Division of Endoscopy, National Cancer Center Hospital, Tokyo, Japan
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Larghi A, Waxman I. State of the art on endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc Clin N Am 2007; 17:441-69, v. [PMID: 17640576 DOI: 10.1016/j.giec.2007.05.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) provide new alternatives for minimally invasive treatment of superficial gastrointestinal malignancies. Evidence suggests that these techniques can be performed safely and have comparable outcomes to surgery with less morbidity and better quality of life due to their tissue-sparing nature when compared with conventional surgery. Although the techniques and accessories have become standardized, there is room for improvement, and further research and development are required. Current challenges facing American gastroenterologists or endoscopic surgeons include access to training and lack of appropriate reimbursement for these heavy-weighted and technically demanding procedures. Nevertheless, EMR and ESD are here to stay and are only the first steps toward true radical endoluminal resection of GI malignancies.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Catholic University, Largo A. Gemelli 8, 00192 Rome, Italy
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Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, Yoshida S, Chayama K. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66:100-7. [PMID: 17591481 DOI: 10.1016/j.gie.2007.02.032] [Citation(s) in RCA: 348] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 02/12/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) has been positively applied to and gradually standardized for early stomach cancer, particularly in Japan. However, because it is technically difficult to perform ESD of the colon, ESD is not a commonly used technique. OBJECTIVE The aim of this study was to evaluate the possibility of standardizing colorectal ESD. SETTING ESD was performed at the Department of Endoscopy, Hiroshima University Hospital. DESIGN Time required for ESD, rate of complete en bloc resection, complication, and postoperative local persistence and recurrence were investigated retrospectively in 70 cases of colorectal neoplasia, wherein the lesion was more than 20 mm in diameter. INTERVENTIONS All lesions were resected by ESD. RESULTS The average (+/-SD) time required for ESD was 70.5+/-45.9 minutes (range, 15-180 minutes), and the histologic rate of complete en bloc resection was 80.0% (56/70). With regard to complication, 1.4% of cases of postoperative hemorrhage (1/70) and 10.0% of cases of perforation (7/70) were observed in total. The rate of perforation was investigated with respect to the type of knife used for ESD and the period after the induction of ESD. The rate of perforation markedly decreased with the practice of the technique. Moreover, the rate of perforation was high when an insulated-tip diathermic knife was used; practicing this technique was insufficient to reduce the rate of perforation. The average duration of follow-up was 614+/-289.5 days, and no case of local persistence and recurrence or metastasis was observed. LIMITATIONS The ESD technique depends on the level of each skill of each colonoscopist. CONCLUSIONS With regard to ESD of the colon, complication, eg, perforation, could be decreased by sufficient practice and selection of an appropriate knife. It is suggested that, in the near future, ESD will be standardized for the colon.
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Affiliation(s)
- Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
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Sumiyama K, Gostout CJ. Novel techniques and instrumentation for EMR, ESD, and full-thickness endoscopic luminal resection. Gastrointest Endosc Clin N Am 2007; 17:471-85, v-vi. [PMID: 17640577 DOI: 10.1016/j.giec.2007.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic intervention is evolving into an established therapeutic alternative for small superficial lesions, and an eventual application for en bloc resection of large lesions, deeper layers, and a reliable access to lesions outside of the gastrointestinal wall. Although further developmental and clinical evaluation is necessary, we believe endoscopic resection by the submucosal route and by full-thickness approaches will replace standard surgical procedures in the next several years.
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Affiliation(s)
- Kazuki Sumiyama
- Mayo Clinic, Developmental Endoscopy Unit, Charlton 8-A, 200 First Street, SW, Rochester, MN 55905, USA
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