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Wei MT, Friedland S, Hwang JH. The Current Landscape of Endoscopic Submucosal Training in the United States. Curr Gastroenterol Rep 2025; 27:4. [PMID: 39509015 DOI: 10.1007/s11894-024-00950-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2024] [Indexed: 11/15/2024]
Abstract
PURPOSE OF REVIEW Endoscopic submucosal dissection (ESD) has been found to increase en bloc and R0 resection as well as decrease risk of recurrence. However, despite literature supporting the benefits of endoscopic submucosal dissection, adoption of ESD in the United States has been challenging, driven by factors including requirement for specialized training as well as limitations in training availability. RECENT FINDINGS Many devices have been developed to improve ease and therefore adoption for the procedure, with advancements in stability, resection as well as closure of the mucosal defect following resection. While the Japanese model of training in ESD centers around the Master-Apprentice model, this is scarce in the United States. Most US endoscopists therefore must follow other paths to learn and become proficient at ESD. There has been a rapid expansion in literature on ESD, fellowship programs, opportunities for case observation, and significant evolution in ex vivo training models that can assist an endoscopist in receiving training in ESD. Currently, there are three main ways of learning to perform ESD in the United States: 1. Third space endoscopy fellowship; 2. Master-apprentice model; 3. Utilization of live courses and proctored procedures. ESD is the optimal method to ensure en bloc resection of large mucosal neoplasms of the gastrointestinal tract. While several barriers hinder adoption of ESD in the United States, there has been significant development both in procedural and training aspects. Further research and discussions are needed to determine criteria for credentialing and proficiency in ESD.
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Affiliation(s)
- Mike T Wei
- Stanford University, Stanford, CA, United States.
| | - Shai Friedland
- Stanford University, Stanford, CA, United States
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Joo Ha Hwang
- Stanford University, Stanford, CA, United States
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Tawheed A, Ismail A, El-Kassas M, El-Fouly A, Madkour A. Endoscopic resection of gastrointestinal tumors: Training levels and professional roles explored. World J Gastrointest Oncol 2025; 17:101832. [PMID: 40235878 PMCID: PMC11995314 DOI: 10.4251/wjgo.v17.i4.101832] [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: 09/27/2024] [Revised: 01/26/2025] [Accepted: 02/11/2025] [Indexed: 03/25/2025] Open
Abstract
In this editorial, we provide commentary on a recently published study by Zhao et al in the World Journal of Gastrointestinal Oncology. The study discusses the clinical characteristics of patients undergoing endoscopic resection for gastric cancers. We feel it is important to engage our endoscopy community in a discussion on the current evidence in the literature on the necessary number of cases for training in endoluminal surgery techniques, particularly endoscopic submucosal dissection. This includes the latest recommendations from the European Society of Gastrointestinal Endoscopy, as well as a summary of key studies on the learning curve for these techniques. Additionally, we explore the impact of an endoscopist's specialty on endoscopy outcomes, drawing from current evidence in the literature to shape our perspective in this evolving field.
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Affiliation(s)
- Ahmed Tawheed
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Alaa Ismail
- Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Mohamed El-Kassas
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Amr El-Fouly
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | - Ahmad Madkour
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
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Chen Y, Chen M, Wang Z, Wu J, Yang J, Yang L, Deng K. Correlation of preoperative CT features with intra- and postoperative parameters of endoscopic resection in patients with gastric submucosal tumor (1~3 cm). Surg Endosc 2025; 39:259-268. [PMID: 39528660 DOI: 10.1007/s00464-024-11349-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 10/09/2024] [Indexed: 11/16/2024]
Abstract
OBJECTIVES Endoscopic resection of gastric submucosal tumors (SMTs) possesses minimal trauma, expedited recovery, and reduced costs. Nonetheless, intraoperative challenges, including imprecise surgical risk assessment, prevail. Hence, we investigated the correlation between preoperative CT observation features and perioperative parameters for predicting outcomes in SMT patients. METHODS Subjects diagnosed with SMT and undergoing endoscopic surgery conducted at West China Hospital's Endoscopy Center from September 2019 to October 2023 were retrospectively selected. Endoscopic ultrasonography (EUS) and computer tomography (CT) were utilized for evaluating SMT. The study assessed the correlation between preoperative CT findings and perioperative parameters. RESULTS Increased lesion size on contrast-enhanced CT correlates with increased operative duration, hospital stay, postoperative antibiotic use. Of utmost significance, we observed a significantly higher intraoperative perforation rate for patients with tumor outgrowth compared to those with lesion involvement of the lumen (96.88% vs 29.11%, P < 0.001). These patients also demonstrated an increased risk of postoperative blood stream infections (P = 0.012), necessitating higher antibiotic grade (P = 0.048), along with prolonged gastrostomy tube retention (P = 0.001) and hospitalization (P = 0.018). In addition, CT provides a more accurate and comprehensive assessment of tumor size (P = 0.037) and growth pattern (P = 0.026) than EUS. CONCLUSION CT assessment of tumor size closer to reality than EUS. Importantly, these features can assist in pinpointing lesions with elevated surgical complexity and high risk of complications, leading to improved preoperative preparation, thereby increasing anticipation of surgical risks and reducing incidence of complications.
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Affiliation(s)
- Yuxiang Chen
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Mo Chen
- Department of Gerontology, Tibetan Chengdu Branch Hospital of West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Department of Gerontology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, 610041, China
| | - Zhu Wang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Junchao Wu
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jinlin Yang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Li Yang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Kai Deng
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Nijjar GS, Aulakh SK, Singh R, Chandi SK. Emerging Technologies in Endoscopy for Gastrointestinal Neoplasms: A Comprehensive Overview. Cureus 2024; 16:e62946. [PMID: 39044885 PMCID: PMC11265259 DOI: 10.7759/cureus.62946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2024] [Indexed: 07/25/2024] Open
Abstract
Gastrointestinal neoplasms are a growing global health concern, requiring prompt identification and treatment. Endoscopic procedures have revolutionized the detection and treatment of gastrointestinal tumors by providing accurate, minimally invasive methods. Early-stage malignancies can be treated with endoscopic excision, leading to improved outcomes and increased survival rates. Precancerous lesions, like adenomatous polyps, can be prevented by removing them, reducing cancer occurrence and death rates. Advanced techniques like chromoendoscopy, narrow-band imaging, and confocal laser endomicroscopy improve the ability to see the mucosa surface and diagnose conditions. Artificial Intelligence (AI) applications in endoscopy can enhance diagnostic accuracy and predict histology outcomes. However, challenges remain in accurately defining lesions and ensuring precise diagnosis and treatment selection. Molecular imaging approaches and therapeutic modalities like photodynamic therapy and endoscopic ultrasonography-guided therapies hold potential but require further study and clinical confirmation. This study examines the future prospects and obstacles in endoscopic procedures for the timely identification and treatment of gastrointestinal cancers. The focus is on developing technology, limits, and prospective effects on clinical practice.
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Affiliation(s)
| | - Smriti Kaur Aulakh
- Internal Medicine, Sri Guru Ram Das University of Health Science and Research, Amritsar, IND
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Zhao AY, Gimpaya N, Angeli Fujiyoshi MR, Fujiyoshi Y, Khan R, Lisondra J, Walsh CM, Grover SC. How to make cost-effective polyp simulators for high-fidelity simulation-based training in postpolypectomy bleeding management and EMR. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:520-526. [PMID: 38155828 PMCID: PMC10751457 DOI: 10.1016/j.vgie.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Video 1Demonstration of manufacturing instructions and features of the postpolypectomy bleeding and conventional and underwater EMR simulators.
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Affiliation(s)
- Ally Y Zhao
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Yusuke Fujiyoshi
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James Lisondra
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Tamari H, Oka S, Kotachi T, Teshima H, Mizuno J, Fukuhara M, Tanaka H, Tsuboi A, Yamashita K, Yuge R, Urabe Y, Kitadai Y, Arihiro K, Tanaka S. Indications for Dental Floss Clip Traction During Gastric Endoscopic Submucosal Dissection by Less-Experienced Endoscopists. J Gastric Cancer 2023; 23:512-522. [PMID: 37932219 PMCID: PMC10630566 DOI: 10.5230/jgc.2023.23.e37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/12/2022] [Accepted: 12/28/2022] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Dental floss clip (DFC) traction-assisted endoscopic submucosal dissection (ESD) is widely performed owing to its simplicity. This study aimed to clarify the appropriate indications for the DFC traction method in early gastric cancer when ESD is performed by less-experienced endoscopists. METHODS AND METHODS We retrospectively analyzed 1,014 consecutive patients who had undergone gastric ESD performed by less-experienced endoscopists between January 2015 and December 2020. Gastric ESD was performed without DFC in all cases before December 2017 [DFC (-) group, 376 cases], and ESD was performed with DFC in all cases after January 2018 [DFC (+) group, 436 cases]. The procedure time and rates of en bloc resection, complete resection, and adverse events of the groups were compared. RESULTS The procedure time did not differ significantly between the 2 groups. However, when comparing lesions >20 mm, the procedure time in the DFC (+) group was significantly shorter than that in the DFC (-) group (95±46 vs. 75±31, P<0.01). The procedure time for lesions located in the greater curvature of the upper or middle stomach and lesions >20 mm located in the lesser curvature side of the stomach in the DFC (+) group was significantly shorter than that in the DFC (-) group. CONCLUSIONS The indications for DFC during gastric ESD by less-experienced endoscopists include lesions located in the greater curvature of the upper or middle stomach, and lesions >20 mm located in the lesser curvature of the stomach.
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Affiliation(s)
- Hirosato Tamari
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan.
| | - Takahiro Kotachi
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hajime Teshima
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Junichi Mizuno
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Motomitsu Fukuhara
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Ryo Yuge
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuji Urabe
- Division of Regeneration and Medicine Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuhiko Kitadai
- Department of Health and Science, Prefectural University of Hiroshima, Hiroshima, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
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Tamari H, Oka S, Kotachi T, Teshima H, Mizuno J, Fukuhara M, Tanaka H, Tsuboi A, Yamashita K, Takigawa H, Yuge R, Urabe Y, Arihiro K, Tanaka S. Efficacy of the specialized scissor-type knife for gastric endoscopic submucosal dissection: a propensity score matched retrospective study. Endosc Int Open 2023; 11:E315-E321. [PMID: 37025153 PMCID: PMC10072925 DOI: 10.1055/a-1971-1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/25/2022] [Indexed: 04/08/2023] Open
Abstract
Background and study aims Prevention of bleeding and perforation during gastric endoscopic submucosal dissection (ESD) is important. Scissor-type knives can accurately grasp and incise the targeted tissue using electrosurgical currents, thereby eliminating unexpected incisions. The SB Knife GX, a scissor-type knife specialized for gastric ESD, was released in June 2016 in Japan. The aim of the present study was to evaluate the efficacy and safety of gastric ESD using the SB Knife GX. Patients and methods A total of 716 patients who underwent gastric ESD at Hiroshima University Hospital between July 2016 and December 2020 were retrospectively reviewed. From these, 671 patients underwent ESD using the IT Knife 2 (IT-2 group), while 45 underwent ESD using an SB Knife GX (SB-GX group). After propensity score matching, the procedure time, specimen size, en bloc and complete resection rates, and intraoperative bleeding, delayed bleeding, and perforation rates were evaluated. Results No significant differences were observed in mean procedure time (SB-GX group: 115 ± 165 min; IT-2 group: 95 ± 61 min; P = 0.82) and en bloc and complete resection rates between the two groups. Intraoperative bleeding rates were significantly lower in the SB-GX group than in the IT-2 group (18 % vs. 40 %; P = 0.01), and there were no differences in delayed bleeding (4 % vs. 4 %) or perforation (0 % vs. 4 %) between the two groups. Conclusions The SB Knife GX was proven to be useful for control of intraoperative bleeding during gastric ESD, although the procedure time tended to be longer.
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Affiliation(s)
- Hirosato Tamari
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Shiro Oka
- Hiroshima University Hospital, Department of Gastroenterology, Hiroshima, Japan
| | - Takahiro Kotachi
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Hajime Teshima
- Hiroshima University Hospital, Department of Gastroenterology, Hiroshima, Japan
| | - Junichi Mizuno
- Hiroshima University Hospital, Department of Gastroenterology, Hiroshima, Japan
| | - Motomitsu Fukuhara
- Hiroshima University Hospital, Department of Gastroenterology, Hiroshima, Japan
| | - Hidenori Tanaka
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Ken Yamashita
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Hidehiko Takigawa
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Ryo Yuge
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
| | - Yuji Urabe
- Hiroshima University Hospital, Department of Gastrointestinal Endoscopy and Medicine, Hiroshima, Japan
| | - Koji Arihiro
- University Hospital, Department of Anatomical Pathology, Hiroshima, Japan
| | - Shinji Tanaka
- Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan
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Yang X, Fu S, Li L, Yang J, Ji R, Li Y, Zuo X. Robot-assisted endoscopic submucosal dissection contributes to efficient and safe learning for novices: Prospective pilot cross-over ex vivo study (with video). Dig Endosc 2023; 35:342-351. [PMID: 36107632 DOI: 10.1111/den.14438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/12/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The lack of effective countertraction to expose the submucosal layer contributes to the technical complication and adverse events in endoscopic submucosal dissection (ESD). We aimed to evaluate the efficacy and safety of a novel endoscopic robot (flexible auxiliary single-arm transluminal endoscopic robot [FASTER]) for ESD learning for novices. METHODS This was a prospective, cross-over designed pilot study in ex vivo porcine stomach. Four ESD novices were randomized to either FASTER-assisted ESD first (FC) group or a conventional ESD first (CF) group, performed 40 gastric ESDs using each technique, then crossed over to another technique. The performance and learning curve were compared between the two groups. RESULTS In the first phase, novices in the FC group demonstrated significantly better performance with shorter procedure time (25.6 ± 7.8 vs. 38.9 ± 13.4 min; P < 0.001) and submucosal dissection time (13.9 ± 5.5 vs. 23.1 ± 11.0 min; P < 0.001), higher direct-vision dissection ratio (84.0 ± 7.9% vs. 43.5 ± 20.7%; P < 0.001), and lower muscular injury (2.5 vs. 40.0%; P < 0.001) and task load (4 vs. 5; P < 0.001). Fewer ESDs were required to gain early proficiency in the FC group. When crossed to the second phase, procedure time in the FC group was prolonged but the muscular injury rate did not increase significantly. In total, endoscopists in the FC group tended to have a lower task load (4 vs. 5; P = 0.008) and less muscular injury (10.0 vs. 21.3%; P = 0.05). CONCLUSION Flexible auxiliary single-arm transluminal endoscopic robot-assisted learning reduces the technical difficulty of ESD for novices and the safety profile can sustain in following conventional ESD. These results indicated that FASTER has potential implications for ESD training in clinical practice.
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Affiliation(s)
- Xiaoxiao Yang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Shichen Fu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Lixiang Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Jialin Yang
- Robo Medical Robotics Institute, Shenzhen Robo Medical Technology Co., Ltd, Shenzhen, China
| | - Rui Ji
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Yanqing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiuli Zuo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
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Risk factors for the failure of endoscopic resection of gastric submucosal tumors: a long-term retrospective case-control study. Gastric Cancer 2022; 25:929-942. [PMID: 35752993 DOI: 10.1007/s10120-022-01306-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/11/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Endoscopic resection (ER) is an effective treatment method for gastric submucosal tumors (G-SMTs), but endoscopic resection failure requires emergency surgery. The purpose of this study was to assess potential risk factors for endoscopic resection failure. METHODS A total of 1041 patients with G-SMT undergoing endoscopic resection were enrolled. Twenty-five patients in whom endoscopic resection failed, requiring a transition to surgery midway through the operation, were included in the failed group, and 1016 patients who received successful endoscopic resection were included in the successful endoscopic resection group. Baseline and lesion characteristics were recorded, and the differences in tumor characteristics and risk factors for resection failure of G-SMT were analyzed. Sensitivity analysis was performed to detect the stability of the indicator. RESULTS Of the 1041cases included, there were 25 cases (2.4%) of failed endoscopic resection. Binary logistic analysis showed that the independent risk factors included tumors originating from deep muscularis propria(OR = 14.42, 95% CI 4.47-46.52), size > 3 cm (OR = 7.75, 95% CI 2.64-22.70), exophytic growth pattern (OR = 4.98, 95% CI 1.62-15.29), endoscopist with less experience (OR = 5.99, 95% CI 1.07-12.19), and irregular borders (OR = 4.13, 95% CI 1.40-12.19). The stable risk factors were tumors size, tumor origin and growth pattern according to sensitivity analysis. CONCLUSIONS Tumors originating from the deep muscularis propria, tumor size > 3 cm, endoscopists with less experience, an exophytic growth pattern, and irregular boundaries were found to be independent risk factors for endoscopic resection failure. To reduce the risk of endoscopic resection failure, physicians should carefully evaluate G-SMT characteristics preoperative.
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Kinoshita J, Iguchi M, Maekita T, Wan K, Shimokawa T, Fukatsu K, Ito D, Taki S, Nishimoto M, Takao M, Tabata Y, Mukai Y, Kitano M. Traction method versus conventional endoscopic submucosal dissection for gastric epithelial neoplasms: A randomized controlled trial. Medicine (Baltimore) 2022; 101:e29172. [PMID: 35421071 PMCID: PMC9276441 DOI: 10.1097/md.0000000000029172] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is an advanced therapeutic technique for en bloc resection of superficial gastrointestinal neoplasms. Although gastric ESD is minimally invasive and provides favorable outcomes, it is technically difficult and requires a long procedure time for dissection. The traction-assisted approach overcomes some of the difficulties of gastric ESD, but its ability to reduce the procedure time remains unclear. The traction-assisted approach using dental floss and a clip did not reduce procedure time in the total population, but it reduced procedure time for lesions limited to the greater curvature of the upper or middle of the stomach. Although the traction direction of the clip-with-line method may be limited to the oral side via the cardia, EndoTrac ESD may provide flexible traction at any time during the procedure. This prospective randomized control study has been designed to compare the efficacy and safety of EndoTrac and conventional gastric ESD. METHODS/DESIGN This multicenter, randomized control trial will enroll 150 patients at 2 hospitals in Japan undergoing EndoTrac or conventional ESD for gastric epithelial neoplasia. Patients with a single gastric epithelial neoplasm who meet the inclusion and exclusion criteria will be randomized to EndoTrac or conventional ESD. Patients will be randomized by a computer-generated random sequence with stratification by operator experience, tumor size, tumor location, and institution. The primary endpoint will be ESD procedure time, defined as the time from the start of the submucosal injection to the completion of resection. Other outcomes will include the rates of adverse events and pathological curability. DISCUSSION The ability of EndoTrac ESD to reduce the long procedure time and/or adverse events observed with conventional ESD can not only reduce physical stress on the patient, but can also reduce length of hospital stay and medical costs. Reduced technical difficulty will contribute to the widespread adoption of this ESD technique worldwide. TRIAL REGISTRATION University Hospital Medial Information Network Clinical Trials Registry (UMIN-CTR), ID: 000044450; Registered on June 6, 2021.https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000050485. PROTOCOL VERSION NUMBER 1.1, March 1, 2022. Patient enrolment began on June 6, 2021 and is expected to be completed by July 19, 2025.
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Affiliation(s)
- Jun Kinoshita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takao Maekita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ke Wan
- Clinical Support Center, Wakayama Medical University, Wakayama, Japan
| | - Toshio Shimokawa
- Clinical Support Center, Wakayama Medical University, Wakayama, Japan
| | - Kazuhiro Fukatsu
- Department of Gastroenterology, Wakayama Rousai Hospital, Wakayama, Japan
| | - Daisaku Ito
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinya Taki
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Nishimoto
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masaki Takao
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasuto Tabata
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yousuke Mukai
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Abstract
With improvements in the early detection of early gastric cancer (EGC) and advances in therapeutic techniques, endoscopic resection (ER) for EGC has become widely adopted in East Asian and Western countries. Endoscopic submucosal dissection has higher rates of en bloc, complete, and curative resections with lower rates of local recurrence than that of endoscopic mucosal resection. ER is a minimally invasive method with low morbidity that provides excellent outcomes. ER for EGC is a safe, effective method, preserving organ function and thus maintaining the patient's quality of life, and is recognized as the first-line treatment of EGC in selected patients.
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Affiliation(s)
- Ga Hee Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, 88, Olympic-ro 43-gil, Songpa-gu, Seoul
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, 88, Olympic-ro 43-gil, Songpa-gu, Seoul.
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Esaki M, Ihara E, Hashimoto N, Abe S, Aratono C, Shiga N, Sumida Y, Fujii H, Haraguchi K, Takahashi S, Iwasa T, Nakano K, Wada M, Somada S, Nishioka K, Minoda Y, Ogino H, Ogawa Y. Efficacy of hybrid endoscopic submucosal dissection with SOUTEN in gastric lesions: An ex vivo porcine model basic study. World J Gastrointest Surg 2021; 13:563-573. [PMID: 34194614 PMCID: PMC8223703 DOI: 10.4240/wjgs.v13.i6.563] [Citation(s) in RCA: 2] [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: 02/09/2021] [Revised: 05/07/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hybrid endoscopic submucosal dissection (ESD) that comprises mucosal incision and partial submucosal dissection followed by snaring in a planned manner, has been developed for endoscopic resection of gastrointestinal neoplasms to overcome the technical barrier of ESD. Although the superiority of hybrid ESD with SOUTEN, a single multifunctional device, over conventional ESD has been indicated, the actual effect of snaring itself remains unclear since SOUTEN could be applied to hybrid ESD group, but not to the conventional ESD group, due to ethical issue in clinical practice.
AIM To determine whether and how hybrid ESD was superior to conventional ESD in the endoscopic treatment of gastric lesions in an ex vivo porcine model basic study.
METHODS Sixteen endoscopists participated in this basic study in August 2020 at Kyushu University, performing 32 procedures each for hybrid ESD and conventional ESD. Mock lesions (10-15 mm, diameter) were created in the porcine stomach. The primary outcome was total procedure time and secondary outcomes were en bloc or complete resection, perforation, procedure time/speed for both, mucosal incision, and submucosal dissection. Factors associated with difficulty in ESD including longer procedure time, incomplete resection, and perforation, were also investigated. Categorical and continuous data were analyzed using the chi-square test or Fisher’s exact test and the Mann-Whitney U test, respectively.
RESULTS The median total procedure time of hybrid ESD was significantly shorter than that of conventional ESD (median: 8.3 min vs 16.2 min, P < 0.001). Time, speed, and the amount of hyaluronic acid during submucosal dissection were more favorable in hybrid ESD than conventional ESD (time, 5.2 min vs 10.4 min, P < 0.001; speed, 43.7 mm2/min vs 23.8 mm2/min, P < 0.00; injection volume, 1.5 mL vs 3.0 mL, P < 0.001), although no significant differences in those factors were observed between both groups during mucosal incision. There was also no significant difference between both groups in the en bloc/complete resection rate and perforation rate (complete resection, 93.8% vs 87.5%, P = 0.67; perforation, 0% vs 3.1%, P = 1). Selection of conventional ESD as the treatment method was significantly associated with difficulties during ESD (odds ratio = 10.2; highest among factors).
CONCLUSION Hybrid ESD with SOUTEN improves the treatment outcomes of gastric lesions. It also has the potential to reduce medical costs since SOUTEN is a single multifunctional device that is inexpensive.
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Affiliation(s)
- Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Norikazu Hashimoto
- Department of Gastroenterology, Fukuoka City Hospital, Fukuoka 811-1394, Japan
| | - Shuichi Abe
- Department of Gastroenterology, Harasanshin Hospital, Fukuoka 812-0033, Japan
| | - Chihoko Aratono
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Koga 811-3195, Japan
| | - Noriko Shiga
- Department of Gastroenterology, Fukuokaken Saiseikai Futsukaichi Hospital, Futsukaichi 811-8516, Fukuoka, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka 810-8564, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Koga 811-3195, Japan
| | - Kazuhiro Haraguchi
- Department of Gastroenterology, Harasanshin Hospital, Fukuoka 812-0033, Japan
| | - Shunsuke Takahashi
- Department of Gastroenterology, Fukuoka City Hospital, Fukuoka 811-1394, Japan
| | - Tsutomu Iwasa
- Department of Gastroenterology, Fukuokaken Saiseikai Futsukaichi Hospital, Futsukaichi 811-8516, Fukuoka, Japan
| | - Kayoko Nakano
- Department of Gastroenterology, Fukuoka Central Hospital, Fukuoka 805-0050, Japan
| | - Masafumi Wada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Shinichi Somada
- Department of Gastroenterology, National Hospital Organization Beppu Medical Center, Beppu 874-0011, Japan
| | - Kei Nishioka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yosuke Minoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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Pih GY, Lee JS, Ahn JY, Kim DH, Na HK, Lee JH, Jung KW, Choi KD, Song HJ, Lee GH, Jung HY. Is Ex Vivo Training before In Vivo Training Effective in Learning Gastric Endoscopic Submucosal Dissection? THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2020.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Arantes VN, Sanna MDGP, Alves JS, Milhomem-Cardoso DM, Maluf-Filho F. IS ENDOSCOPIC SUBMUCOSAL DISSECTION STILL LIMITED TO FEW TERTIARY CENTERS IN THE WEST? RESULTS FROM A NATIONAL SURVEY IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2021; 57:477-483. [PMID: 33331480 DOI: 10.1590/s0004-2803.202000000-84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers. OBJECTIVE This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED). METHODS In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided. RESULTS A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers. CONCLUSION ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.
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Affiliation(s)
- Vitor N Arantes
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Instituto Alfa de Gastroenterologia, Unidade de Endoscopia, Belo Horizonte, MG, Brasil.,Hospital Mater Dei Contorno, Unidade de Endoscopia, Belo Horizonte, MG, Brasil
| | - Maria das Graças Pimenta Sanna
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Instituto Alfa de Gastroenterologia, Unidade de Endoscopia, Belo Horizonte, MG, Brasil
| | - Jairo Silva Alves
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Instituto Alfa de Gastroenterologia, Unidade de Endoscopia, Belo Horizonte, MG, Brasil
| | | | - Fauze Maluf-Filho
- Instituto do Câncer do Estado de São Paulo (ICESP), Unidade de Endoscopia, SP, Brasil
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15
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Hsu WH, Wu TS, Hsieh MS, Kung YM, Wang YK, Wu JY, Yu FJ, Kuo CH, Su YC, Wang JY, Wu DC, Hu HM. Comparison of Endoscopic Submucosal Dissection Application on Mucosal Tumor and Subepithelial Tumor in stomach. J Cancer 2021; 12:765-770. [PMID: 33403034 PMCID: PMC7778549 DOI: 10.7150/jca.47653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/04/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Endoscopic submucosal dissection is minimal invasive endoscopic procedure to deal with gastric tumor. Initially, it was developed to resect mucosal neoplasm since 2000 and extended its application to submucosal tumor in the following years. Although the basic ESD skills are similar in gastric mucosal tumor and subepithelial tumor, the success rate, complication may be different between the two types of gastric tumor resection. This retrospective study is conducted to analyze the ESD procedure in gastric mucosal tumor and subepithelial tumor. Methods: From 2007 to 2016, we reviewed all patients who underwent endoscopic submucosal dissection for gastric mucosal tumor and subepithelial tumor in Kaohsiung Medical University Hospital. Results: Totally, 35 patients with gastric subepithelial tumor and 41 patients with gastric mucosal tumor received endoscopic submucosal dissection are enrolled. Among 35 patients with subepithelial tumor, 32 (91.4%) patients achieved curative treatment. 1 patient received emergent operation and 2 patients received salvage operation to complete tumor resection. 8 patients (22.9%) occurred perforation and no delay bleeding was found. Among 41 patients with mucosal neoplasm, 30 (71.4%) patients achieved curative treatment. 2 patients received emergent operation and 9 patients received salvage operation to complete tumor resection. 9 patients (21.9%) occurred complication, 6 patients occurred delay bleeding and 3 patients had perforation. Conclusions: Comparing ESD between gastric mucosal tumor and subepithelial tumor, ESD had similar efficiency in curative treatment. However, ESD in subepethelial tumor encountered higher perforation and lesser delay bleeding.
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Affiliation(s)
- Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzung-Shiun Wu
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Meng-Shu Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yu-Min Kung
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Yao-Kuang Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jeng-Yih Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fang-Jung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Yu-Chung Su
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
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16
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Esaki M, Suzuki S, Horii T, Ichijima R, Yamakawa S, Shibuya H, Kusano C, Ikehara H, Gotoda T. Reduction in the procedure time of hybrid endoscopic submucosal dissection for early gastric neoplasms: a multi-center retrospective propensity score-matched analysis. Therap Adv Gastroenterol 2020; 13:1756284820939420. [PMID: 32821288 PMCID: PMC7412903 DOI: 10.1177/1756284820939420] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/02/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) for early gastric neoplasms is still a technically difficult and time-consuming procedure. Hybrid ESD (H-ESD) involves circumferential incision with partial submucosal dissection combined with subsequent mucosal resection by snaring, wherein the newly developed device allows us to perform H-ESD using a single device. This study aimed to determine the clinical outcomes of H-ESD compared with conventional ESD (C-ESD) for early gastric neoplasms. METHODS In this multi-center, retrospective study, using propensity score-matched analysis, we reviewed the charts of patients with early gastric neoplasms smaller than 20 mm treated with H-ESD or C-ESD at three hospitals between January 2017 and October 2018. The primary outcome was the procedure time, and the secondary outcomes were other factors, including the en bloc resection rate, complete resection rate, curative resection rate, and rate of adverse events. RESULTS Among 215 patients, 29 underwent H-ESD and 186 underwent C-ESD; 29 pairs were created by propensity score matching. In the H-ESD group, 82.8% of lesions met the absolute indication [mucosal lesions limited to 20-mm diameter, dominated by differentiated adenocarcinoma without ulcer (scar)] for endoscopic resection (ER). As a result, the procedure time of H-ESD was significantly shorter than that of C-ESD [20 (interquartile range, 12-27) min versus 40 (30-50) min; p < 0.001]. There was no significant difference in the secondary outcomes between the two groups. CONCLUSION H-ESD contributed to reduced procedure time. Therefore, H-ESD could be an alternative endoscopic treatment for gastric neoplasms when the lesion fulfils the absolute indication for ER.
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Affiliation(s)
- Mitsuru Esaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Yuri-Kumiai General Hospital, Akita, Japan
| | - Toshiki Horii
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Yuri-Kumiai General Hospital, Akita, Japan
| | - Ryoji Ichijima
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shun Yamakawa
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hitoshi Shibuya
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Yuri-Kumiai General Hospital, Akita, Japan
| | - Chika Kusano
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Department of Gastroenterology, Yuri-Kumiai General Hospital, Akita, Japan
| | - Hisatomo Ikehara
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 1–6, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8309, Japan
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Fujiwara J, Matsumoto S, Yamanaka K, Sekine M, Ishii T, Ajimine T, Mashima H. Introduction of gastric endoscopic submucosal dissection and skill acquisition in a regional hospital. JGH Open 2020; 4:230-235. [PMID: 32280769 PMCID: PMC7144776 DOI: 10.1002/jgh3.12249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/01/2019] [Accepted: 08/04/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD) is standard treatment for early gastric cancer. With aging of the population in Japan being more pronounced in rural areas, the availability of ESD at regional hospitals is becoming important. Here, we assessed the learning curve of one physician for skill acquisition in gastric ESD. METHODS The subjects were 34 patients (38 lesions) who underwent gastric ESD at a regional hospital between October 2014 and March 2017 and 15 patients (15 lesions) who underwent the procedure at a university hospital between April 2017 and April 2018. The resection periods of the first 19 lesions and subsequent 19 lesions at the regional hospital were defined as the first and seconds periods, and the resection period of 15 lesions at the university hospital was defined as the third period. The learning curve across the three periods was assessed using the cumulative sum analysis method. RESULTS The resection speed in the first, second, and third periods were 6.4 ± 4.1, 6.9 ± 3.4, and 9.4 ± 5.4 mm2/min, respectively (not significant). The slope of the learning curve began to increase at the 30th patient. The en bloc resection and curative resection rates did not differ significantly among the three periods. There were no serious procedure-related complications. CONCLUSION This study showed that the introduction of gastric ESD at a regional hospital is possible, and that a certain skill level was acquired by the 30th patient. Furthermore, with careful patient selection, favorable results can be obtained and procedural safety ensured.
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Affiliation(s)
- Junichi Fujiwara
- Department of Gastroenterology, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Kenichi Yamanaka
- Department of Gastroenterology, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Masanari Sekine
- Department of Gastroenterology, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Takehiro Ishii
- Department of Gastroenterology, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Takuma Ajimine
- Department of GastroenterologyKitaakita City HospitalAkitaJapan
| | - Hirosato Mashima
- Department of Gastroenterology, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
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18
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Yu X, Chen J, Yuan Z, Liu H, Liu F, Liu Y, Xue L, He S, Zhang Y, Dou L, Liu X, Zhao D, Li J, Wang S, Zhang P, Lu N, Wang G. Endoscopic resection techniques for squamous premalignant lesions and early carcinoma of the esophagus: ER-Cap, MBM, and ESD, how do we choose? A multicenter experience. Therap Adv Gastroenterol 2020; 13:1756284820909172. [PMID: 32215053 PMCID: PMC7065281 DOI: 10.1177/1756284820909172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 02/04/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic resection cap technique (ER-Cap), multiband mucosectomy (MBM), and endoscopic submucosal dissection (ESD) have been widely applied in the treatment of esophageal squamous neoplasia and cancer. However, little is known with regards to the comparison of these methods. This study aimed to compare the feasibility, safety, effectiveness, and costs of these three techniques. METHODS A retrospective analysis of patients with squamous premalignant or early malignant lesions of the esophagus undergoing ER-Cap, MBM, or ESD from January 2009 to December 2015 in one of the centers in China was performed. The procedural data and follow-up data for all patients were recorded. RESULTS A total of 672 patients with 733 lesions were included; 148 lesions (133 patients) were treated with ER-Cap, 427 lesions (388 patients) with MBM, and 158 lesions (151 patients) with ESD. The mean age was 61.59 years and the male-to-female ratio was 2.78:1. The operation time was significantly shorter for ER-Cap (29.26 ± 16.73 mins, p < 0.001) group, and the hospitalization costs were significantly lower in the MBM group (20,942.03 ± 8435.56￥, p = 0.003). The resection sample size of ESD was significantly larger (4.40 ± 1.20 cm, p < 0.001) and the en bloc resection rate of ESD was significantly higher (p < 0.001) than that of the other two groups. The frequencies of perforation, bleeding, and cicatricial stenosis were significantly lower in the MBM group (p < 0.001, p = 0.011, p = 0.009). Three local recurrences were observed in the ER-Cap group, while no recurrence was observed in MBM and ESD groups. There were three and two metastatic patients observed in the MBM and ESD groups, respectively. CONCLUSIONS ER-Cap, MBM, and ESD are all minimally invasive, safe, and effective methods for treating early esophageal squamous cell carcinoma. MBM could be considered as a good alternative when performed by a less-experienced endoscopist in high-incidence areas with limited resources.
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Affiliation(s)
- Xinying Yu
- Department of endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Chen
- Department of Early diagnosis and treatment of cancer, Feicheng Peoples Hospital, Shandong, China
| | - Zhiqiang Yuan
- Department of Early diagnosis and treatment of cancer, Yanting Cancer Hospital, Sichuan, China
| | - Hui Liu
- Department of Gastroenterology, Changzhi Peoples Hospital, Shanxi, China
| | - Fugang Liu
- Department of Early diagnosis and treatment of cancer, Dongping Peoples Hospital, Shandong, China
| | - Yong Liu
- Department of endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liyan Xue
- Department of pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shun He
- Department of endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yueming Zhang
- Department of endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lizhou Dou
- Department of endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Liu
- Department of endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Deli Zhao
- Department of Early diagnosis and treatment of cancer, Feicheng Peoples Hospital, Shandong, China
| | - Jun Li
- Department of Early diagnosis and treatment of cancer, Yanting Cancer Hospital, Sichuan, China
| | - Shaofeng Wang
- Department of Gastroenterology, Changzhi Peoples Hospital, Shanxi, China
| | - Ping Zhang
- Department of Early diagnosis and treatment of cancer, Dongping Peoples Hospital, Shandong, China
| | - Ning Lu
- Department of pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kim SG, Hwang JH. How to decrease the risk of perforation in endoscopic submucosal dissection (ESD). TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Mocker L, Hildenbrand R, Oyama T, Sido B, Yahagi N, Dumoulin FL. Implementation of endoscopic submucosal dissection for early upper gastrointestinal tract cancer after primary experience in colorectal endoscopic submucosal dissection. Endosc Int Open 2019; 7:E446-E451. [PMID: 30931376 PMCID: PMC6428673 DOI: 10.1055/a-0854-3610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Current guidelines recommend endoscopic submucosal dissection (ESD) as a treatment option for early cancers of the upper gastrointestinal tract with absent or minimal risk of lymph node metastasis. However, due to the low prevalence of these entities, it is difficult to achieve a competence level for ESD of upper gastrointestinal tract cancers in the Western World. Here, we present single-center data on the implementation of upper gastrointestinal ESD after previous experience with 89 colorectal ESD cases. Methods Retrospective case series of 39 consecutive patients with early cancers of the esophagus (n = 13) or cardia and stomach (n = 26) treated with ESD over a 4-year period. Results ESD was technically feasible in all cases with en bloc, R0, and curative resection rates of 100 %, 76.9 %, and 71.8 %, respectively, and a mean procedure time of 100 minutes (30 - 360 minutes). After an initial 20 procedures, the R0 and curative resection rates increased from 65.0 % to 89.5 %, and from 60.0 % to 84.2 %, respectively. Complications were observed in four patients (10.3 %): three perforations, one case of delayed bleeding, and one esophageal stricture. No case required emergency surgery; the 30-day mortality rate was 0 %. Conclusion In this modest case series from Europe, we observed an effectiveness and complication rate for ESD for early esophageal and gastric cancer that are comparable to other series from Europe but also to more abundant data from Asia. The results indicate that even small numbers of upper gastrointestinal cancers can be managed adequately in centers with expertise in colorectal ESD.
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Affiliation(s)
- Lena Mocker
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | | | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Bernd Sido
- Department of General and Abdominal Surgery, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
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Hayashi Y, Esaki M, Suzuki S, Ihara E, Yokoyama A, Sakisaka S, Hosokawa T, Tanaka Y, Mizutani T, Tsuruta S, Iwao A, Yamakawa S, Irie A, Minoda Y, Hata Y, Ogino H, Akiho H, Ogawa Y. Clutch Cutter knife efficacy in endoscopic submucosal dissection for early gastric neoplasms. World J Gastrointest Oncol 2018; 10:487-495. [PMID: 30595802 PMCID: PMC6304306 DOI: 10.4251/wjgo.v10.i12.487] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/15/2018] [Accepted: 11/08/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the outcomes of endoscopic submucosal dissection (ESD) for gastric neoplasms using Clutch Cutter (ESD-C) or other knives (ESD-O).
METHODS This was a single-center retrospective study. Gastric neoplasms treated by ESD between April 2016 and October 2017 at Kitakyushu Municipal Medical Center were reviewed. Multivariate analyses and propensity score matching were used to reduce biases. Covariates included factors that might affect outcomes of ESD, including age, sex, underlying disease, anti-thrombotic drugs use, tumor location, tumor position, tumor size, tumor depth, tumor morphology, tumor histology, ulcer (scar), and operator skill. The treatment outcomes were compared among two groups. The primary outcome was ESD procedure time. Secondary outcomes were en bloc, complete, and curative resection rates, and adverse events rates including perforation and delayed bleeding.
RESULTS A total of 155 patients were included in this study; 44 pairs were created by propensity score matching. Background characteristics were quite similar among two groups after matching. Procedure time was significantly shorter for ESD-C (median; 49 min) than for ESD-O (median; 88.5 min) (P < 0.01). However, there was no significant difference in treatment outcomes between ESD-C and ESD-O including en bloc resection rate (100% in both groups), complete resection rate (100% in both groups), curative resection rate (86.4% vs 88.6%, P = 0.730), delayed bleeding (2.3% vs 6.8%, P = 0.62) and perforation (0% in both groups).
CONCLUSION ESD-C achieved shorter procedure time without an increase in complication risk. Therefore, ESD-C could become an effective ESD option for gastric neoplasms.
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Affiliation(s)
- Yasuyo Hayashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Itabashi-ku 173-8610, Japan
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Itabashi-ku 173-8610, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Azusa Yokoyama
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Seiichiro Sakisaka
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Taizo Hosokawa
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Yoshimasa Tanaka
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Takahiro Mizutani
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Shinichi Tsuruta
- Department of Anatomic Pathology, Graduate School of Medical Sciences Kyushu University, Fukuoka 812-8582, Japan
| | - Aya Iwao
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Itabashi-ku 173-8610, Japan
| | - Shun Yamakawa
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Itabashi-ku 173-8610, Japan
| | - Akira Irie
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Itabashi-ku 173-8610, Japan
| | - Yosuke Minoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Hirotada Akiho
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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22
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Esaki M, Suzuki S, Hayashi Y, Yokoyama A, Abe S, Hosokawa T, Tsuruta S, Minoda Y, Hata Y, Ogino H, Akiho H, Ihara E, Ogawa Y. Propensity score-matching analysis to compare clinical outcomes of endoscopic submucosal dissection for early gastric cancer in the postoperative and non-operative stomachs. BMC Gastroenterol 2018; 18:125. [PMID: 30081824 PMCID: PMC6080519 DOI: 10.1186/s12876-018-0855-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 07/31/2018] [Indexed: 02/07/2023] Open
Abstract
Background Endoscopic submucosal dissection (ESD) of the postoperative stomach (ESD-P) for early gastric cancer (EGC) is considered a technically difficult procedure. However, it is difficult to compare the outcomes of ESD-P and ESD of the non-operative stomach (ESD-N) because their baseline characteristics are different. Therefore, we aimed to compare the technical outcomes of ESD-P with those of ESD-N using a propensity score-matching analysis to compensate for the differences. Methods The chart records of 1046 patients with EGC who were treated with ESD between January 2004 and July 2016 at Kitakyushu Municipal Medical Center in Japan were reviewed in this retrospective study. Multivariate analyses and propensity score-matching were performed for age, sex, lesion location, lesion size, tumor invasion, tumor size, ulcer (scar), and operator skill. The primary outcome was procedure time. Secondary outcomes were percentages of en bloc, complete, and curative resections, and percentages of adverse events, which were evaluated between the two groups. Results Forty-one patients were in the ESD-P group and 1005 patients were in the ESD-N group. Propensity score-matching created 41 matched pairs. According to the adjusted comparisons, ESD-P required a significantly longer procedure time (85 min vs 51 min, p < 0.001). Other treatment outcomes showed an en bloc resection rate of 100% for both groups (p = 1) and complete resection rates of 95.1 and 97.6% (p = 1), curative resection rates of 90.2 and 90.2% (p = 1), perforation during ESD rates of 2.4 and 0% (p = 1), and postprocedure bleeding rates of 2.4 and 2.4% (p = 1) for the ESD-P and ESD-N groups, respectively. For the ESD-P group, lesions on the suture line or anastomotic site were significantly associated with longer procedure times (p = 0.038). Conclusions ESD-P was a more time-consuming procedure than ESD-N. However, ESD-P and ESD-N achieved high rates of curative resection with a low rate of adverse events for the treatment of EGC. ESD could be selected as the treatment for EGC even in the postoperative stomach provided that careful attention is given to lesions on the suture line or anastomotic site.
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Affiliation(s)
- Mitsuru Esaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8309, Japan. .,Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan.
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8309, Japan
| | - Yasuyo Hayashi
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan.,Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Azusa Yokoyama
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Shuichi Abe
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Taizo Hosokawa
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Shinichi Tsuruta
- Department of Anatomic Pathology, Graduate School of Medical Sciences Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yosuke Minoda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hirotada Akiho
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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23
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Endoscopic eradication therapy for Barrett’s esophagus: Adverse outcomes, patient values, and cost-effectiveness. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kim B, Kim BJ, Seo IK, Kim JG. Cost-effectiveness and short-term clinical outcomes of argon plasma coagulation compared with endoscopic submucosal dissection in the treatment of gastric low-grade dysplasia. Medicine (Baltimore) 2018; 97:e0330. [PMID: 29642169 PMCID: PMC5908624 DOI: 10.1097/md.0000000000010330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic treatment such as endoscopic submucosal dissection (ESD) or argon plasma coagulation (APC) is widely performed to treat gastric low-grade dysplasia (LGD). We aimed to evaluate the clinical efficacy of APC versus ESD for gastric LGD in terms of cost-effectiveness. This was a retrospective review of patients with gastric LGD who were treated with endoscopic intervention (APC or ESD) between March 2011 to December 2015. Fifty-nine patients treated with APC and 124 patients treated with ESD were included. Patients in the APC group were significantly older (mean age, 67.68 vs 63.90 years, respectively, P < .01), had an increased rate of Helicobacter pylori infection (27.1 vs 10.5%, respectively, P < .01), and had a higher mean Charlson Comorbidity Index score (2.32 vs 0.38, respectively, P < .01) than those in the ESD group. The 2 groups did not differ in tumor size, location, macroscopic morphology, or surface configuration. The procedure time (11.31 vs56.44 minutes, respectively, P < .01), and hospital stay (3.2 vs 5.6 days, respectively, P < .01) were significantly, shorter in the APC group than in the ESD group. Additionally, the cost incurred was significantly, lower in the APC group than in the ESD group (962.03 vs 2,534.80 dollars, respectively, P < .01). APC has many advantages related to safety, and cost-effectiveness compared with ESD. Therefore, APC can be considered an alternative treatment option for gastric LGD.
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25
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Esaki M, Suzuki S, Hayashi Y, Yokoyama A, Abe S, Hosokawa T, Ogino H, Akiho H, Ihara E, Ogawa Y. Splash M-knife versus Flush Knife BT in the technical outcomes of endoscopic submucosal dissection for early gastric cancer: a propensity score matching analysis. BMC Gastroenterol 2018; 18:35. [PMID: 29486717 PMCID: PMC5832194 DOI: 10.1186/s12876-018-0763-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/23/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancer. A new multi-functional ESD device was developed to achieve complete ESD with a single device. A metal plate attached to its distal sheath achieves better hemostasis during the procedure than the other needle-knife device, Flush Knife BT®, that has been conventionally used. The aim of this study was to compare the technical outcomes of ESD for early gastric cancer using the Splash M-Knife® with those using the Flush Knife BT. METHODS We conducted a retrospective review of the case records of 149 patients with early gastric cancer treated with ESD using the needle-type ESD knives between January 2012 and August 2016 at Kitakyushu Municipal Medical Center. Lesions treated with ESD using the Splash M-knife (ESD-M) and the Flush Knife BT (ESD-F) were compared. Multivariate analyses and propensity score matching were used to compensate for the differences in age, gender, underlying disease, antithrombotic drug use, lesion location, lesion position, macroscopic type, tumor size, presence of ulceration, operator level and types of electrosurgical unit used. The primary endpoint was the requirement to use hemostatic forceps in the two groups. The secondary endpoints of procedure time, en bloc and complete resection rates, and adverse events rates were evaluated for the two groups. RESULTS There were 73 patients in the ESD-M group, and 76 patients in the ESD-F group. Propensity score matching analysis created 45 matched pairs. Adjusted comparisons between the two groups showed a significantly lower usage rate of hemostatic forceps in the ESD-M group than in the ESD-F group (6.7% vs 84.4%, p < 0.001). Treatment outcomes showed an en bloc resection rate of 100% in both groups; complete resection rate of 95.6% vs 100%, p = 0.49; median procedure time of 74.0 min vs 71.0 min, p = 0.90; post-procedure bleeding of 2.2% vs 2.2%, p = 1, in the ESD-M and ESD-F groups, respectively. There were no perforations in either group. CONCLUSIONS ESD-M appeared to reduce the usage of hemostatic forceps during ESD for early gastric cancer without increasing the adverse effects. Thus, it may contribute to a reduction in the total ESD cost.
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Affiliation(s)
- Mitsuru Esaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8309, Japan. .,Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan.
| | - Sho Suzuki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8309, Japan
| | - Yasuyo Hayashi
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Azusa Yokoyama
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Shuichi Abe
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Taizo Hosokawa
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Haruei Ogino
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan.,Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hirotada Akiho
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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26
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Küttner-Magalhães R, Dinis-Ribeiro M, Bruno MJ, Marcos-Pinto R, Rolanda C, Koch AD. Training in endoscopic mucosal resection and endoscopic submucosal dissection: Face, content and expert validity of the live porcine model. United European Gastroenterol J 2017; 6:547-557. [PMID: 29881610 DOI: 10.1177/2050640617742484] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/17/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction Endoscopic mucosal resection and endoscopic submucosal dissection are demanding procedures. This study aims to establish face, content and expert validity of the live porcine model in performing endoscopic mucosal resection, endoscopic submucosal dissection, complication management and to assess it as a training tool. Material and methods Tutors and trainees participating in live porcine model endoscopic mucosal resection and endoscopic submucosal dissection workshops filled out a questionnaire regarding the realism of the model compared to human setting and its role as a learning tool. A 10-point Likert scale was used. Results Ninety-one endoscopists (13 tutors; 78 trainees) were involved in four workshops. Median global classifications for the realism of the life porcine model ranged between 7.0-8.0 (interquartile range 5.0-9.0). Procedures resembled human cases with a median of 9.0 (8.0-9.0) for oesophageal multiband endoscopic mucosal resection; 8.5 (8.0-9.0) for oesophageal endoscopic submucosal dissection; 9.0 (8.0-10.0) for gastric endoscopic submucosal dissection; and 9.0 (8.5-9.75 and 8.0-9.69) for complication detection and management. The animal model as a learning tool had median scores of 9.0 (7.0-10.0) considering how procedures are performed; 9.0-9.5 (8.0-10.0) for usefulness for beginners; and 9.0-10.0 (5.0-10.0) regarding it a prerequisite. Conclusions Training in a live porcine model was considered very realistic compared to the human setting and was highly appreciated as a learning tool. This is the first study to establish face, content and expert validity of the live porcine model in performing multiband endoscopic mucosal resection, oesophageal and gastric endoscopic submucosal dissection. The validation of this model provides the rationale to incorporate it into formal teaching programmes.
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Affiliation(s)
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Oncology Portuguese Institute of Porto, Porto, Portugal.,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS) and Center for Research in Health Technologies and Services (CINTESIS), Faculty of Medicine of Porto, Porto, Portugal
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ricardo Marcos-Pinto
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Centre, Portugal.,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS) and Center for Research in Health Technologies and Services (CINTESIS), Faculty of Medicine of Porto, Porto, Portugal.,Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Carla Rolanda
- Department of Gastroenterology, Braga Hospital, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga, Portugal
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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27
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Resection outcomes and recurrence rates of endoscopic submucosal dissection (ESD) and hybrid ESD for colorectal tumors in a single Italian center. Surg Endosc 2017; 32:2328-2339. [DOI: 10.1007/s00464-017-5928-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/08/2017] [Indexed: 12/21/2022]
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28
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Saccomandi P, Quero G, Costamagna G, Diana M, Marescaux J. Effects of Nd:YAG laser for the controlled and localized treatment of early gastrointestinal tumors: Preliminary in vivo study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:4533-4536. [PMID: 29060905 DOI: 10.1109/embc.2017.8037864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endoscopic submucosal dissection (ESD) is a minimally invasive technique allowing for the removal of early gastrointestinal (GI) tumors, widely considered as a valid alternative to conventional surgery. However, ESD is technically demanding, and potentially severe complications, such as bleeding and perforation, may occur. Energy-based techniques (e.g., radiofrequency ablation) might offer a potential alternative to ESD. However, their use mandates the ability to predict the damage induced and to identify a "signature" of the complete ablation, without the need for a physical specimen. Ideally, an energy-based procedure should be tunable in order to limit the ablation to the superficial layers, namely mucosa (M) and submucosa (SM), without injuring the muscularis propria (MP), thereby minimizing GI perforation. This experimental study aims to investigate thermal damage induced by Nd:YAG laser on the gastric wall, at different laser settings such as power (P) and time (t). Laser ablation was performed on the stomach wall of 6 Wistar rats. Two powers (2.5W and 1.0W) and 3 exposure times (12s, 6s and 2s) were tested, for a total of 30 ablations. Histological analysis allowed to assess thermal damage, in terms of damage depth (DD) and identification of involved layers. The ratio (R) between DD and the total depth (TD) of target layers (M+SM) was used as an index to evaluate the effectiveness of laser settings. At P=2.5W, MP was damaged (R>1) in the majority of cases (11/15). At P=1.0W, MP was preserved in all tests (R<;1), and rarely (4/15) did the damage reach the whole SM (R=1). Histopathological analysis evidenced that tissue damage was strongly related to the variable tissue thickness. These preliminary results seem to support the fact that endoscopic tunable laser ablation is feasible with a consistent damage/power correlation. Further tests are required to optimize the settings for applications on early GI tumors.
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Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States. Gastrointest Endosc 2017; 86:600-607. [PMID: 27688205 DOI: 10.1016/j.gie.2016.09.023] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The role of endoscopic submucosal dissection (ESD) in Barrett's early neoplasia is not well defined, with most studies originating from Asia and Europe. We aimed to assess the efficacy, safety, and results of ESD in Barrett's esophagus (BE) with high-grade dysplasia (HGD) and early adenocarcinoma (EAC) across centers in the United States. METHODS Multicenter retrospective analysis on 46 patients with BE who underwent ESD for BE-HGD or EAC, or both, between January 2010 and April 2015. The primary endpoint was the rate of en bloc resection. Secondary aims included rate of R0 (complete) and curative resection, a comparison of pre- and post-ESD histology, procedure-related adverse events, and rate of remission at follow-up. RESULTS Median age was 69 years (range, 42-82 years). The median resected specimen size was 45 mm (range, 13-125 mm). En bloc and curative resection rates were 96% (44/46) and 70% (32/46), respectively. Most lesions (11/20; 55%) diagnosed as BE-HGD on biopsy were upstaged to intramucosal or invasive EAC on post-ESD histopathology. There were 4 early (<48 hours) adverse events (3 bleeding and 1 perforation), and all were treated endoscopically. Seven patients (15%) developed esophageal strictures that were managed endoscopically. Complete remission of BE neoplasia was found in 100% (32/32) of patients with curative resection at median follow-up of 11 months (range, 2-25 months). CONCLUSIONS This is the largest multicenter series of ESD for early neoplastic BE from the United States. ESD appears to be safe and effective, with high en bloc and curative resection rates in the treatment of early BE neoplasia.
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30
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Usefulness of the S-O clip for gastric endoscopic submucosal dissection (with video). Surg Endosc 2017; 32:908-914. [PMID: 28733749 DOI: 10.1007/s00464-017-5765-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 07/14/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is technically one of the most complicated endoscopic procedures. Traction methods have been reported to be effective for ESD. A recent study revealed that the S-O clip allowed faster and safer colonic ESD. We assessed the efficacy and safety of gastric ESD with the S-O clip for gastric epithelial neoplasm. METHODS We performed a retrospective cohort study of patients treated for gastric ESD using the S-O clip between September and November 2016 (SO group, n = 48). The subjects were matched with patients treated with conventional gastric ESD from September 2015 to August 2016 (control group, n = 258) at Sendai Kousei Hospital, a tertiary endoscopic center. The primary outcome was procedure time. Multivariate logistic regression and propensity score matching analyses were performed to reduce the effects of selection bias for potential confounding factors differences like age, sex, lesion location, lesion position, presence of ulcer scarring, resected specimen size, and operator experiences. RESULTS Forty-eight pairs were created after propensity score matching. The mean procedure time (including the S-O clip attachment time) was significantly shorter in the SO group (47.2 ± 24.6 vs. 69.2 ± 67.1 min, p = 0.035). The mean clip attachment time was 4.4 (range 2-15) min. There were no significant differences in other treatment outcomes (en-bloc resection rate: 100 vs. 100%, p = 1.000; perforation rate: 0 vs. 2.1%, p = 0.315; delayed bleeding rate: 2.1 vs. 4.3%, p = 0.558). CONCLUSIONS The S-O clip improved the speed of gastric ESD by approximately 25%, without increasing adverse events.
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Mortagy M, Mehta N, Parsi MA, Abe S, Stevens T, Vargo JJ, Saito Y, Bhatt A. Magnetic anchor guidance for endoscopic submucosal dissection and other endoscopic procedures. World J Gastroenterol 2017; 23:2883-2890. [PMID: 28522906 PMCID: PMC5413783 DOI: 10.3748/wjg.v23.i16.2883] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/24/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is a well-established, minimally invasive treatment for superficial neoplasms of the gastrointestinal tract. The universal adoption of ESD has been limited by its slow learning curve, long procedure times, and high risk of complications. One technical challenge is the lack of a second hand that can provide traction, as in conventional surgery. Reliable tissue retraction that exposes the submucosal plane of dissection would allow for safer and more efficient dissection. Magnetic anchor guided endoscopic submucosal dissection (MAG-ESD) has potential benefits compared to other current traction methods. MAG-ESD offers dynamic tissue retraction independent of the endoscope mimicking a surgeon's "second hand". Two types of magnets can be used: electromagnets and permanent magnets. In this article we review the MAG-ESD technology, published work and studies of magnets in ESD. We also review the use of magnetic anchor guidance systems in natural orifice transluminal endoscopic surgery and the idea of magnetic non-contact retraction using surface ferromagentization. We discuss the current limitations, the future potential of MAG-ESD and the developments needed for adoption of this technology.
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Akutsu D, Suzuki H, Narasaka T, Terasaki M, Kaneko T, Matsui H, Mizokami Y, Hyodo I. Waterjet submucosal dissection of porcine esophagus with the HybridKnife and ERBEJET 2 system: a pilot study. Endosc Int Open 2017; 5:E30-E34. [PMID: 28337481 PMCID: PMC5361881 DOI: 10.1055/s-0042-122335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Esophageal endoscopic submucosal dissection (ESD) is technically difficult because of narrow working spaces and ease of perforation due to the lack of serosa. HybridKnife is a recently developed ESD device that is combined with the high pressure waterjet ERBEJET 2 system to lift mucosa. We hypothesized that this waterjet could make submucosal dissection safer and studied this in porcine esophagus. Materials and methods Water pressures of 30 - 70 bar were tested to determine the appropriate pressure for waterjet ESD with HybridKnife (WJ-ESD) in one pig. WJ-ESD safety and completion were compared with those of conventional ESD using DualKnife (C-ESD) as a reference. Each of three virtual esophageal lesions in two pigs were resected alternatively using both methods from the lower to upper esophagus. For WJ-ESD, the submucosa, apart from hard fibrous tissues, was dissected using water pressure alone. Results Using 50 bar of water pressure resulted in the best balance between proper dissection and view-disturbing water backflow. The dissection speeds for the lower, middle, and upper esophagus were 0.2, 0.9, and 0.2 cm2/min in 50 bar WJ-ESD and 1.1, 0.5, and 1.0 cm2/min in C-ESD, respectively. Minor bleeding was frequent in WJ-ESD, but was easily stopped by electrocoagulation with the same needle. No perforation was observed in either procedure. Thermal damage to dissected tissues appeared mild, and the extent of muscle injury was lower for WJ-ESD (4, 6, and 8 %) compared with C-ESD (14, 16, and 7 %). Conclusions WJ-ESD could be completed safely for porcine esophagus with less damage to the muscle layer compared with C-ESD.
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Affiliation(s)
- Daisuke Akutsu
- Department of Gastroenterology, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, Japan,Corresponding author Daisuke Akutsu, MD Department of GastroenterologyUniversity of Tsukuba1-1-1, TennodaiTsukubaIbaraki 305-8575Japan+81-29-8533218
| | - Hideo Suzuki
- Division of Endoscopy, University of Tsukuba Hospital, 2-1-1, Amakubo, Tsukuba, Ibaraki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, Japan
| | - Masahiko Terasaki
- Department of Gastroenterology, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, Japan
| | - Tsuyoshi Kaneko
- Department of Gastroenterology, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, Japan
| | - Hirofumi Matsui
- Department of Gastroenterology, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, Japan
| | - Yuji Mizokami
- Division of Endoscopy, University of Tsukuba Hospital, 2-1-1, Amakubo, Tsukuba, Ibaraki, Japan
| | - Ichinosuke Hyodo
- Department of Gastroenterology, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, Japan
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Mortagy M, Mehta N, Parsi MA, Abe S, Stevens T, Vargo JJ, Saito Y, Bhatt A. Magnetic anchor guidance for endoscopic submucosal dissection and other endoscopic procedures. World J Gastroenterol 2017; 23:2883. [DOI: https:/doi.org/10.3748/wjg.v23.i16.2883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
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Yoshida M, Kakushima N, Mori K, Igarashi K, Kawata N, Tanaka M, Takizawa K, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H, Ono H. Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators. Surg Endosc 2016; 31:3614-3622. [PMID: 28039646 DOI: 10.1007/s00464-016-5393-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 12/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) represents a significant progress in therapeutic endoscopy, little is known about how trainees attain its technical proficiency. The aims of this study were to evaluate the learning curve and clinical outcomes of gastric ESD performed by trainee endoscopists. METHODS Between April 2009 and March 2014, 334 gastric ESD procedures were performed by seven trainees (42-50 consecutive cases per trainee). The learning curve for gastric ESD was evaluated using the cumulative sum (CUSUM) method. Long-term outcomes were also analyzed. RESULTS The calculated CUSUM learning curve comprised three phases: Phase I (the initial 15 cases), Phase II (the middle 15 cases), and Phase III (the final 20 cases). The resection speed was 5.7 ± 3.2 min/cm2 in Phase I, 4.7 ± 2.7 min/cm2 in Phase II, and 4.3 ± 2.2 min/cm2 in Phase III. The resection speed was significantly faster in Phase II than in Phase I (p = 0.019). The rate of self-completion reached more than 95% in Phases II and III. The overall complete resection rate was 95%, showing no significant differences between the three phases. Local recurrence was diagnosed in none of the patients during a median follow-up of 38 months. CONCLUSIONS For the trainees, 30 cases were required to attain a higher technical level of competence in gastric ESD. After the learning curve phase, trainee operators could be expected to complete the procedure successfully with favorable long-term outcomes.
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Affiliation(s)
- Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, Japan
| | - Kimihiro Igarashi
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
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Bhurwal A, Bartel MJ, Heckman MG, Diehl NN, Raimondo M, Wallace MB, Woodward TA. Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia. Gastrointest Endosc 2016; 84:959-968.e7. [PMID: 27109458 DOI: 10.1016/j.gie.2016.04.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/12/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Colorectal EMR for nonpolypoid neoplasia achieves better outcomes when performed by expert endoscopists. The time point at which the endoscopist achieves expert level remains to be defined. The objective of this study was to establish a learning curve of colorectal EMR for nonpolypoid neoplasia based on residual tissue on surveillance colonoscopy and adverse event rate. METHODS Five hundred seventy-eight consecutive patients underwent EMR of colorectal neoplasia by 1 of 3 primary endoscopists between December 2004 and September 2013 in a tertiary academic center. Primary analyses focused on the largest lesion for patients with more than 1 lesion (median age, 69 years; median polyp size, 30 mm; 51% en bloc resection). Data on surveillance colonoscopy were available for 74%. Learning curves were calculated for each of the 3 main outcome measurements: the presence of residual neoplasia on surveillance colonoscopy, endoscopic assessment of incomplete EMR, and the occurrence of an immediate bleeding adverse event. RESULTS Residual neoplasia on surveillance colonoscopy was present for 23.2% of patients, the rate of endoscopist-assessed incomplete EMR was 27.6%, and immediate bleeding adverse events occurred in 6.9% of patients. Although there was between-endoscopist variability, the overall rates of residual neoplasia and incomplete EMR decreased to below 20% to 25% after 100 EMRs; initial decreases in both rates were observed for earlier EMRs. Immediate bleeding adverse events occurred at a low frequency for each endoscopist across all EMRs. Perforation requiring surgical intervention occurred in 1 patient (0.2%). CONCLUSIONS This study demonstrated that an unexpectedly high number of 100 colorectal EMR procedures for large nonpolypoid colorectal neoplasia are required to achieve a plateau phase for crucial outcomes.
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Affiliation(s)
- Abhishek Bhurwal
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael J Bartel
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
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Choi IJ, Lee NR, Kim SG, Lee WS, Park SJ, Kim JJ, Lee JH, Kwon JW, Park SH, You JH, Kim JH, Lim CH, Cho JY, Kim GH, Lee YC, Jung HY, Kim JY, Chun HJ, Seol SY. Short-Term Outcomes of Endoscopic Submucosal Dissection in Patients with Early Gastric Cancer: A Prospective Multicenter Cohort Study. Gut Liver 2016; 10:739-748. [PMID: 27172929 PMCID: PMC5003197 DOI: 10.5009/gnl15466] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/11/2015] [Accepted: 12/16/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) is an effective treatment for early gastric cancer (EGC) that has demonstrated a minimal risk of lymph node metastasis in retrospective studies. We sought to prospectively evaluate the short-term outcomes of ESD treatment in EGCs. METHODS A prospective multicenter cohort study of neoplasms 3 cm or less in diameter at endoscopic size evaluation was performed in 12 Korean ESD study grouprelated university hospitals and the National Cancer Center. Resected specimens were evaluated by the central pathologic review board. RESULTS A patient cohort (n=712) with a total of 737 EGCs was analyzed. The margin-free en bloc resection rate was 97.3%, and curative resection of 640 lesions (86.8%) was achieved. Lower curative resection rates were associated with lesions 2 to 3 cm in size prior to ESD compared with lesions 2 cm or less in size (78.6% vs 88.1%, respectively, p=0.009). Significant factors associated with noncurative resection were moderately or poorly differentiated histological type, posterior wall tumor location, tumor size larger than 3 cm, ulceration, and submucosal invasion. Delayed bleeding occurred in 49 patients (6.9%), and 12 patients (1.7%) exhibited perforations. CONCLUSIONS ESD is an effective treatment with a high curative resection rate for EGCs that meets relatively conservative pre-ESD indications. Long-term survival outcomes should be evaluated in followup studies.
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Affiliation(s)
- Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang,
Korea
| | - Na Rae Lee
- National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul,
Korea
| | - Wan Sik Lee
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan,
Korea
| | - Jae J. Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jin-Won Kwon
- National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu,
Korea
| | - Seung-Hee Park
- National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Ji Hye You
- National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan,
Korea
| | - Chul-Hyun Lim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul,
Korea
| | - Joo Young Cho
- Digestive Disease Center, Soonchunhyang University Hospital, Seoul,
Korea
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam,
Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan,
Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ji Young Kim
- National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
| | - Hoon Jai Chun
- Department of Internal Medicine, Institute of Digestive Diseases and Nutrition, Korea University College of Medicine, Seoul,
Korea
| | - Sang-Yong Seol
- National Evidence-Based Healthcare Collaborating Agency, Seoul,
Korea
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan,
Korea
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Nagai K, Uedo N, Yamashina T, Matsui F, Matsuura N, Ito T, Yamamoto S, Hanaoka N, Takeuchi Y, Higashino K, Ishihara R, Iishi H. A comparative study of grasping-type scissors forceps and insulated-tip knife for endoscopic submucosal dissection of early gastric cancer: a randomized controlled trial. Endosc Int Open 2016; 4:E654-60. [PMID: 27556074 PMCID: PMC4993886 DOI: 10.1055/s-0042-105870] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/21/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is technically difficult for beginners. Few comparative studies of technical feasibility, efficacy, and safety using various devices have been reported. This study evaluated the feasibility, efficacy, and safety of ESD for EGC < 2 cm using grasping-type scissors forceps (GSF) or insulated-tip knife (IT2) for three resident endoscopists. PATIENTS AND METHODS This was a randomized phase II study in a cancer referral center. A total of 108 patients with 120 EGCs were enrolled with the following characteristics: differentiated-type mucosal EGC, without ulcers or scars, < 2 cm (86 men, 22 women; median age 72 years). All lesions were stratified according to operator and tumor location (antrum or corpus), assigned randomly to two groups (GSF or IT2), and resected by ESD. Self-completion rate, complete resection rate, procedure time, and adverse events were evaluated as main outcome measures. RESULTS There was no difference in self-completion rate between the IT2 group (77 %, 47/61, P = 0.187) and the GSF group (66 %, 37/56). Also, there were no differences in en bloc resection rate (98 %, 60/61 vs. 93 %, 52/56, P = 0.195) and adverse events (3.3 %, 2/61 vs. 7.1 %, 4/56, P = 0.424). Median (min [range]) procedure time in the IT2 group (47 [33 - 67], P = 0.003) was shorter than that in the GSF group (66 [40 - 100]). Limitations of this study were the small sample size and single center design. CONCLUSIONS ESD with GSF did not show a statistically significant advantage in improvement of self-completion rate over IT2. ( STUDY REGISTRATION UMIN 000005048).
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Affiliation(s)
- Kengo Nagai
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan,Corresponding author Noriya Uedo, MD Department of Gastrointestinal OncologyOsaka Medical Center for Cancer and Cardiovascular Diseases3-3, Nakamichi 1-chomeHigashinari-kuOsaka, 537-8511Japan+81-6-6981-4067
| | - Takeshi Yamashina
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Fumi Matsui
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Takashi Ito
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Noboru Hanaoka
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Hiroyasu Iishi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Suzuki S, Gotoda T, Kobayashi Y, Kono S, Iwatsuka K, Yagi-Kuwata N, Kusano C, Fukuzawa M, Moriyasu F. Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos). Gastrointest Endosc 2016; 83:337-46. [PMID: 26320698 DOI: 10.1016/j.gie.2015.07.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although endoscopic submucosal dissection (ESD) is a significant advancement in therapeutic endoscopy, it is a complicated technique and requires considerable expertise. In this exploratory study, we evaluated the efficacy of a simple traction method that uses dental floss and a hemoclip (DFC) and was developed to overcome the technical difficulties of ESD. METHODS In total, 238 early gastric cancers treated by ESD between May 2012 and December 2014 at Tokyo Medical University were retrospectively reviewed. Lesions treated by conventional ESD (n = 185) and by ESD with DFC (ESD-DFC) (n = 53) were compared. Multivariable analyses and propensity score matching were used to compensate for the differences in age, sex, resected specimen size, lesion location, lesion position, presence of ulceration, and operator level. The procedure time, rate of en bloc and complete resection, and rates of adverse events were evaluated between the 2 groups. RESULTS Propensity score matching analysis created 43 matched pairs. Adjusted comparisons between ESD-DFC and conventional ESD showed similar treatment outcomes (en bloc resection rate: 97.7% vs 100%, P = .315; complete resection rate: 90.7% vs 95.3%, P = .397; perforation during ESD rate: 2.3% vs 2.3%, P = 1.000; post-ESD bleeding rate: 4.7% vs 4.7%, P = 1.000) but a significantly shorter procedure time for ESD-DFC (82.2 ± 79.5 minutes vs 118.2 ± 71.6 minutes, P = .002). CONCLUSION ESD-DFC facilitated rapid ESD with good visualization and traction while ensuring high curability and safety.
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Affiliation(s)
- Sho Suzuki
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yoshiyuki Kobayashi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shin Kono
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kunio Iwatsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naoko Yagi-Kuwata
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Chika Kusano
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | | | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Oyama T, Yahagi N, Ponchon T, Kiesslich T, Berr F. How to establish endoscopic submucosal dissection in Western countries. World J Gastroenterol 2015; 21:11209-11220. [PMID: 26523097 PMCID: PMC4616199 DOI: 10.3748/wjg.v21.i40.11209] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/06/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been invented in Japan to provide resection for cure of early cancer in the gastrointestinal tract. Professional level of ESD requires excellent staging of early neoplasias with image enhanced endoscopy (IEE) to make correct indications for ESD, and high skills in endoscopic electrosurgical dissection. In Japan, endodiagnostic and endosurgical excellence spread through personal tutoring of skilled endoscopists by the inventors and experts in IEE and ESD. To translocate this expertise to other continents must overcome two fundamental obstacles: (1) inadequate expectations as to the complexity of IEE and ESD; and (2) lack of suitable lesions and master-mentors for ESD trainees. Leading endoscopic mucosal resection-proficient endoscopists must pioneer themselves through the long learning curve to proficient ESD experts. Major referral centers for ESD must arise in Western countries on comparable professional level as in Japan. In the second stage, the upcoming Western experts must commit themselves to teach skilled endoscopists from other referral centers, in order to spread ESD in Western countries. Respect for patients with early gastrointestinal cancer asks for best efforts to learn endoscopic categorization of early neoplasias and skills for ESD based on sustained cooperation with the masters in Japan. The strategy is discussed here.
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Chiu PW, Phee SJ, Bhandari P, Sumiyama K, Ohya T, Wong J, Poon CCY, Tajiri H, Nakajima K, Ho KY. Enhancing proficiency in performing endoscopic submucosal dissection (ESD) by using a prototype robotic endoscope. Endosc Int Open 2015; 3:E439-42. [PMID: 26528498 PMCID: PMC4612240 DOI: 10.1055/s-0034-1393178] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/26/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS One of the challenges in performing endoscopic submucosal dissection (ESD) is the lack of counter traction during submucosal dissection. MASTER (Master and Slave Transluminal Endoscopic Robot) was designed to allow performance of complex endoluminal procedures using two arms with excellent control. This study aimed to compare the performance of ESD between endoscopists and novices using MASTER. METHODS This is a prospective study comparing the differences in performing ESD using MASTER in an ex vivo porcine stomach model among individuals with or without experience in surgery and endoscopy. Multiple standardized lesions of 20 mm(2) were pre-marked on an ex vivo porcine stomach. Each participant received basic training in controlling MASTER before the ESD procedure. The operative time and size of specimen obtained by each participant were noted. RESULTS Nine individuals (three ESD expert endoscopists, three ESD non-expert endoscopists, and three non-clinician novices) participated in the experiment. All participants completed the ESD procedure for en bloc resection of standardized lesions using EndoMASTER without perforation. The mean times (mean ± SD) taken by ESD expert endoscopists, ESD non-expert endoscopists, and novices to complete Robotic ESD were 122 ± 58 s, 203 ± 150 s, and 561 ± 496 s, respectively. There was no statistically significant difference in the mean operative time to complete the ESD between the three groups (P = 0.242). When the performance of the six endoscopists was compared to that of the three novices, the endoscopists took an average of 162 ± 111 s to complete the ESD, while the non-clinicians required an average of 561 ± 496 s (P = 0.085). CONCLUSIONS There was a trend to shorter operative time when comparing endoscopists to non-endoscopists in performing ESD using MASTER. The use of MASTER enabled the novice without endoscopy experience to complete the ESD procedure.
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Affiliation(s)
- Philip WaiYan Chiu
- CUHK Jockey Club Minimally Invasive Surgical Skills Center, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Soo Jay Phee
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
| | - Pradeep Bhandari
- Solent Centre for Digestive Diseases, Queen Alexandra Hospital, Portsmouth, UK
| | - Kazuki Sumiyama
- Department of Gastroenterology and Hepatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomohiko Ohya
- Department of Gastroenterology and Hepatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Jennie Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carmen CY Poon
- CUHK Jockey Club Minimally Invasive Surgical Skills Center, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hisao Tajiri
- Department of Gastroenterology and Hepatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiyokazu Nakajima
- Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Khek Yu Ho
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Division of Gastroenterology and Hepatology, University Medical Cluster, National University Health System, Singapore, Singapore,Corresponding author Khek Yu Ho, MD Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore+65-67794112
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Pasricha S, Cotton C, Hathorn KE, Li N, Bulsiewicz WJ, Wolf WA, Muthusamy VR, Komanduri S, Wolfsen HC, Pruitt RE, Ertan A, Chmielewski GW, Shaheen NJ. Effects of the Learning Curve on Efficacy of Radiofrequency Ablation for Barrett's Esophagus. Gastroenterology 2015; 149:890-6.e2. [PMID: 26116806 PMCID: PMC4584171 DOI: 10.1053/j.gastro.2015.06.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/11/2015] [Accepted: 06/17/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Complete eradication of Barrett's esophagus (BE) often requires multiple sessions of radiofrequency ablation (RFA). Little is known about the effects of case volume on the safety and efficacy of RFA or about the presence or contour of learning curves for this procedure. METHODS We collected data from the US RFA Patient Registry (from 148 institutions) for patients who underwent RFA for BE from July 2007 to July 2011. We analyzed the effects of the number of patients treated by individual endoscopists and individual centers on safety and efficacy outcomes of RFA. Outcomes, including stricture, bleeding, hospitalization, and complete eradication of intestinal metaplasia (CEIM), were assessed using logistic regression. The effects of center and investigator experience on numbers of treatment sessions to achieve CEIM were examined using linear regression. RESULTS After we controlled for potential confounders, we found that as the experience of endoscopists and centers increased with cases, the numbers of treatment sessions required to achieve CEIM decreased. This relationship persisted after adjusting for patient age, sex, race, length of BE, and presence of pretreatment dysplasia (P < .01). Center experience was not significantly associated with overall rates of CEIM or complete eradication of dysplasia. We did not observe any learning curve with regard to risks of stricture, gastrointestinal bleeding, perforation, or hospitalization (P > .05). CONCLUSIONS Based on analysis of a large multicenter registry, efficiency of the treatment, as measured by number of sessions needed to achieve CEIM, increased with case volume, indicating a learning curve effect. This trend began to disappear after treatment of approximately 30 patients by the center or individual endoscopist. However, there was no significant association between safety or efficacy outcomes and previous case volume.
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Affiliation(s)
- Sarina Pasricha
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cary Cotton
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kelly E Hathorn
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nan Li
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William J Bulsiewicz
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - W Asher Wolf
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - V Raman Muthusamy
- Division of Gastroenterology, Department of Medicine, UCLA School of Medicine, Los Angeles, California
| | - Srinadh Komanduri
- Division of Gastroenterology, Department of Medicine, Northwestern University School of Medicine, Chicago, Illinois
| | - Herbert C Wolfsen
- Division of Gastroenterology, Department of Medicine, Mayo Clinic Florida, Jacksonville, Florida
| | - Ron E Pruitt
- Nashville Gastrointestinal Specialists, Nashville, Tennessee
| | - Atilla Ertan
- Division of Gastroenterology, Department of Medicine, University of Texas School of Medicine, Houston, Texas
| | - Gary W Chmielewski
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Rush Medical College, Chicago, Illinois
| | - Nicholas J Shaheen
- Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Boo SJ, Jung JH, Park JH, Na SY, Kim SO, Park SH, Yang DH, Kim KJ, Ye BD, Myung SJ, Yang SK, Kim JH, Byeon JS. An adequate level of training for technically competent colonoscopic polypectomy. Scand J Gastroenterol 2015; 50:908-15. [PMID: 25623342 DOI: 10.3109/00365521.2015.1006672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
GOALS The purpose of this study is to investigate the learning curve for colonoscopic polypectomy (CP) by trainee endoscopists. BACKGROUND The amount of training required to achieve technical competence for CP is uncertain. STUDY The CP times and en bloc resection rates of three experienced colonoscopists were obtained from 240 procedures. These data were compared to those of three gastroenterology trainees who performed 750 CP procedures. A trainee procedure was deemed to be a success if en bloc resection was obtained and the CP time was within twice the median CP time of the experienced colonoscopists. Trainees were deemed to be technically competent when they achieved a CP success rate of greater than or equal to 80%. RESULTS The median CP times and en bloc resection rates for the experienced colonoscopists and trainees were 79 s (range, 20-301 s) and 99.6% (239/240), and 118 s (range, 36-1051 s) and 95.6% (717/750), respectively. The trainee success rate of CP was 72% (540/750). The success rate of the procedure was associated with increased trainee experience (p = 0.003) and reached 80% after 250 procedures. The CP time significantly decreased (p < 0.001) and en bloc resection rate significantly increased (p = 0.011) as trainee experience accumulated. The level of experience was an independent predictor for successful CP. CONCLUSIONS The achievement of technical competence with CP was associated with an accumulation of approximately 250 procedures. These findings suggest that dedicated education and training programs for CP are warranted.
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Affiliation(s)
- Sun-Jin Boo
- Department of Internal medicine, Jeju National University School of Medicine , Jeju , Korea
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Aslan F, Alper E, Cekıc C, Yurtlu DA, Ekıncı N, Arabul M, Unsal B, Mıura Y, Yamamoto H. Endoscopic submucosal dissection in gastric lesions: the 100 cases experience from a tertiary reference center in West. Scand J Gastroenterol 2015; 50:368-75. [PMID: 25582554 DOI: 10.3109/00365521.2014.999253] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) is an endoscopic treatment method widely used in premalignant and malignant lesions in countries of the Far East. This method, which is difficult technically and has a high complication risk rate, has rarely been performed in the West, because of the fewer number of upper gastrointestinal lesions. In the present study, we aimed to present our results of gastric ESD procedures in respect to the learning curve. METHODS A total of 100 ESD procedures, which were performed in the stomach between April 2012 and September 2014, were recorded prospectively before and after the procedure. Patient data were analyzed retrospectively. ESD procedures were numbered chronologically; the first 30 patients constituted group 1, whereas the rest were classified as the group 2. ESD results were compared between the groups. RESULTS In a total of 95 patients, 100 gastric ESDs were performed. The overall en-bloc and complete resection rates were 93% and 92%, respectively. In respect of the learning curve, there were significant differences in the sizes of lesions and tissues obtained, procedure duration and dissection rate, snare use and knife preferences between groups (p = 0.002, p < 0.001, p = 0.003, p < 0.001, p = 0.009, and p < 0.001, respectively). No significant difference was detected in the en-bloc and complete resection rates and complications between the groups. CONCLUSION According to guideline recommendations and masters for ESD, if ESD training is initiated and continued, successful ESD may be performed in localized lesions in the stomach.
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Affiliation(s)
- Fatih Aslan
- Department of Gastroenterology, Ataturk Training and Research Hospital, Katip Celebi University , Izmir , Turkey
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Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection. Gastrointest Endosc 2015; 81:333-41.e1. [PMID: 25281498 DOI: 10.1016/j.gie.2014.07.047] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/17/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Endoscopic resection (ER) of early gastric cancer (EGC) meeting the absolute indication has excellent long-term outcomes. OBJECTIVE To compare long-term outcomes of ER with those of surgery in patients with EGC who met the absolute indication for ER. DESIGN Retrospective cohort study. SETTING A specialized center for the treatment of cancer. PATIENTS AND INTERVENTIONS We retrospectively reviewed data from patients who underwent gastrectomy or ER for EGC between 2002 and 2007. Gastric cancers were differentiated-type adenocarcinoma without ulceration confined to the mucosal layer and 2 cm or smaller in size. MAIN OUTCOME MEASUREMENTS The primary outcome was overall survival (OS). Metachronous cancer rates and adverse event rates were compared. Kaplan-Meier plots and Cox proportional hazard regression analyses were applied for comparisons. Differences in baseline characteristics were adjusted by propensity score. RESULTS Among 375 patients, 261 underwent ER and 114 underwent surgery. The median follow-up duration was 76.4 months. The 5-year OS rates did not significantly differ between the ER and surgery groups (95.7% vs 93.6%, respectively; P = .725 by log-rank test). There were no gastric cancer-related deaths in either group. Metachronous gastric cancer developed more frequently in the ER group (6.1%, 16/261) than in the surgery group (0.9%, 1/114) (P = .024). However, most patients (93.8%, 15/16) in the ER group were curatively treated with repeat ER. Adverse event rates were higher in the surgery group than those in the ER group (7.9% vs 2.7%, P = .028). LIMITATIONS Retrospective, single-center study. CONCLUSIONS The OS rate after ER for mucosal gastric cancer that met the absolute indication was comparable to that achieved with surgery. Although metachronous cancers were more common after ER, they were usually treatable and did not affect survival.
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Yoshida N, Fernandopulle N, Inada Y, Naito Y, Itoh Y. Training methods and models for colonoscopic insertion, endoscopic mucosal resection, and endoscopic submucosal dissection. Dig Dis Sci 2014; 59:2081-2090. [PMID: 25102984 DOI: 10.1007/s10620-014-3308-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/17/2014] [Indexed: 12/17/2022]
Abstract
Colonoscopic examination is considered an effective examination for the detection of colorectal cancers. Additionally, early colorectal cancers can be resected using endoscopic techniques such as endoscopic mucosal resection and endoscopic submucosal dissection. However, those examinations and treatments need special techniques. Various training methods are practiced to acquire such endoscopic techniques throughout the world. In clinical cases, magnetic positioning devices help endoscopic insertion by less experienced endoscopists. There is a physical model made by polyvinyl chloride and a virtual simulator for training of colonoscopic insertion. Various techniques including a method to apply pressure to the abdomen and consideration for patient's pain can be trained using these models. In view of extensive training of endoscopic mucosal resection and endoscopic submucosal dissection, animal models are useful and actually used. Live animal models of minipig, which entails blood flow, are ideal and used frequently, but are cumbersome to prepare. On the other hand, ex vivo animal models using intestine of porcine and bovine are convenient for preparation and less expensive. Unique ex vivo animal models with blood flow have been developed recently and techniques for hemostasis can be practiced. With respect to a method of training for colorectal endoscopic submucosal dissection, a stepwise system has been adopted throughout the world. Thus, first they observe the expert's technique, then practice training of animal models, and finally, they perform clinical rectal cases. The system is useful for a safe and definite procedure. In this review, we reveal various training methods for colonoscopic examinations and treatments.
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Affiliation(s)
- Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan,
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Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a widely accepted method for the treatment of early gastrointestinal neoplasms. OBJECTIVES To investigate the learning curve of ESD performed by a single endoscopist focusing on developing the performance of dissection, shortening the procedure time, and preventing complications. PATIENTS AND METHODS Records of 120 consecutive ESD procedures performed by a single endoscopist with an ESD knife from December 2007 to April 2013 were collected. For analysis of the learning curve, total procedures were divided into four periods, each comprising 30 sequential ESD procedures. Adjusted procedure time (min) was calculated as specimen area [π×long length (mm)×short length (mm)/4]÷procedure time. The parameters assessed were the en-bloc resection rate, complete resection rate, duration and speed of procedure time, and related complications. RESULTS Procedure times were significantly longer with lesions located at the upper third of the stomach and with the specimen sizes exceeding 1500 mm. There were significant differences in the adjusted overall procedure time from the first to the third quarter (19.9±11.0 vs. 30.3±11.8, P=0.01) and to the fourth quarter (19.9±11.0 vs. 35.8±15.7, P<0.01), and from the second to the third quarter (21.1±8.3 vs. 30.3±11.8, P=0.04) and to the fourth quarter (21.1±8.3 vs. 35.8±15.7, P<0.01). CONCLUSION ESD for gastric neoplasms can be performed with a steady speed after the experience of 60 ESD procedures with proper clinical outcomes. Further studies with different endoknives will be required for ESD operators as a reference.
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Uesato M, Nabeya Y, Akai T, Inoue M, Watanabe Y, Horibe D, Kawahira H, Hayashi H, Matsubara H. Monitoring salivary amylase activity is useful for providing timely analgesia under sedation. World J Gastrointest Endosc 2014; 6:240-247. [PMID: 24932376 PMCID: PMC4055993 DOI: 10.4253/wjge.v6.i6.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 04/02/2014] [Accepted: 05/28/2014] [Indexed: 02/05/2023] Open
Abstract
AIM To detect the criteria and cause of elevated salivary amylase activity (sAMY) in patients undergoing endoscopic submucosal dissection (ESD) under sedation. METHODS A total of 41 patients with early gastric cancer removed via ESD under deep sedation (DS) were enrolled. The perioperative sAMY, which was shown as sympathetic excitements (SE), was measured. The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level (IR, %) ≥ 100% (twice the actual value) was assumed as the moment when the patient received SE. Among the 41 patients, we focused on 14 patients who exhibited an IR ≥ 100% at any time that was associated with sAMY elevation during ESD (H-group) and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level. If a patient demonstrated an elevated sAMY level above twice the baseline level, the endoscopic procedure was immediately stopped. In the impossible case of discontinuance, analgesic medicines were administered. This study was performed prospectively. RESULTS A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group. The baseline level of sAMY significantly increased in association with an IR of > 100% at 5 min, with a significant difference (IR immediately before elevation/IR at elevation of sAMY = 8.72 ± 173/958 ± 1391%, P < 0.001). However, effective intervention decreased the elevated sAMY level immediately within only 5 min, with a significant difference (IR at sAMY elevation/immediately after intervention = 958 ± 1391/476 ± 1031, P < 0.001). The bispectral indices, systolic blood pressure and pulse rates, which were measured at the same time, remained stable throughout the ESD. Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes. Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level, independent of body movement. CONCLUSION By detecting twice the actual sAMY based on the preoperative level, the release of the gastric wall tension or the administration of analgesic agents should be considered.
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Abstract
Endoscopic submucosal dissection (ESD) is a well-established advanced mucosal resection technique used in Japan, where it originated, and some other Asian countries. The technical difficulty and potentially higher rates of significant complications have been obstacles for its dissemination across the United States, on top of the lack of available equipment, candidate lesions in the gastrointestinal tract, and adequate training programs. Yet American physicians are becoming increasingly aware of the benefits of ESD. Simplification of technique, modification of tools and materials, and improved availability of training opportunities are essential in order to accelerate the adoption of ESD in the United States.
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Affiliation(s)
- Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B158, Aurora, CO 80045, USA.
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Clinical significance of intraperitoneal air on computed tomography scan after endoscopic submucosal dissection in patients with gastric neoplasms. Surg Endosc 2013; 28:307-13. [DOI: 10.1007/s00464-013-3188-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 08/07/2013] [Indexed: 12/28/2022]
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Tomizawa Y, Iyer PG, Wong Kee Song LM, Buttar NS, Lutzke LS, Wang KK. Safety of endoscopic mucosal resection for Barrett's esophagus. Am J Gastroenterol 2013; 108:1440-7; quiz 1448. [PMID: 23857478 PMCID: PMC3815637 DOI: 10.1038/ajg.2013.187] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 05/09/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic mucosal resection (EMR) is an established technique for the management of Barrett's esophagus (BE). Although EMR is generally perceived to be a relatively safe procedure, the published data regarding EMR-related complications are variable and the expertise of those performing EMR is often not disclosed. Our aim was to determine the complication rates in a large cohort of patients who underwent EMR at a specialized BE unit. METHODS A prospectively maintained database was reviewed for patients with BE who underwent EMR from January 1995 to August 2008. EMR was performed in patients with neoplastic appearing lesions. Bleeding, stricture, and perforation related to EMR were reviewed as the main outcome measurements. RESULTS In all, 681 patients (83% male; mean age 70 years old) underwent a total of 1,388 endoscopic procedures and 2,513 EMRs. Median length of BE was 3.0 cm (interquartile range (IQR) 1-7). A single experienced endoscopist performed 99% of the EMR procedures. EMR was performed using commercially available EMR kits in 95% (77% cap-snare and 18% band-snare) and a variceal band ligation device in 5% of cases. No EMR-related perforations occurred during the study period. The rate of post-EMR bleeding was 1.2% (8 patients). Seven patients were successfully treated endoscopically and one needed surgery. The rate for symptomatic strictures after EMR was 1.0% (7 cases), and all of the cases did not involve intervening ablation therapies. All strictures were successfully treated with endoscopic dilation. CONCLUSIONS This is the largest series reported to date on EMR in BE. In this large retrospective study, EMR for BE was associated with a low rate of complications for selected patients when performed by experienced hands.
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Affiliation(s)
- Yutaka Tomizawa
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G. Iyer
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Louis M. Wong Kee Song
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Navtej S. Buttar
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori S. Lutzke
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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