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1
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Mou TT, Xu Y, Qian LZ, Mao XL, Zheng HH, Zhang Y. Esophageal mucosal auto-transplantation versus acellular dermal matrix transplantation for preventing esophageal stenosis after endoscopic resection in patients with superficial esophageal mucosal lesions. Surg Endosc 2025:10.1007/s00464-025-11718-0. [PMID: 40325245 DOI: 10.1007/s00464-025-11718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 04/06/2025] [Indexed: 05/07/2025]
Abstract
BACKGROUND Esophageal stricture is the principal complication associated with endoscopic resection (ER) in patients with superficial esophageal cancer (SEC), and medical intervention may be required to prevent esophageal stricture after ER. The aim of this study was to compare acellular dermal matrix (ADM) transplantation and esophageal mucosal autograft (EMA) transplantation in terms of efficacy in preventing esophageal stricture after ER for SEC. METHODS Between May 2017 and November 2022, 48 patients with SEC who underwent EMA or ADM after ER were enrolled in this study. The primary outcomes measured included esophageal stricture, refractory esophageal stricture, and the number of endoscopic dilations after esophageal stricture. RESULTS A total of 48 patients with SEC were enrolled in this study, 17 of whom underwent EMA after ER (EMA group) and 31 of whom underwent ADM after ER (ADM group). The median of total procedure duration and the median of transplantation duration in the ADM group was significantly shorter than that in the EMA group (Z = - 2.408, P = 0.016; Z = - 2.710, P = 0.006). During the follow-up, 4 patients developed refractory esophageal stricture in the EMA group and 1 developed refractory esophageal stricture in the ADM group. The rate of refractory esophageal stricture was lower in ADM group than in EMA group (3.2% vs. 23.5%, P = 0.047). In patients with > 3/4 circumferential range ER, the rate of refractory esophageal stricture was also lower in ADM group than in EMA group (4.0% vs. 25.0%, P = 0.067). Among the patients who developed esophageal stricture, the median number of endoscopic dilations in the ADM group was less than that in the EMA group (Z = 27.500; P = 0.040). CONCLUSIONS Compared with EMA, ADM provided several advantages, as it reduced the number of endoscopic dilations for patients with esophageal strictures and shortened the procedure duration for patients who underwent esophageal ESD.
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Affiliation(s)
- Ting-Ting Mou
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Shaoxing University, Shaoxing, Zhejiang, China
- Department of Gastroenterology, the First People's Hospital of Wenling, Wenzhou Medical University, Wenling, Zhejiang Province, China
| | - Yue Xu
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Shaoxing University, Shaoxing, Zhejiang, China
| | - Ling-Zhu Qian
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, 150 Ximen Street, Linhai, Zhejiang, China
| | - Xin-Li Mao
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Shaoxing University, Shaoxing, Zhejiang, China
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, 150 Ximen Street, Linhai, Zhejiang, China
| | - Hai-Hong Zheng
- Department of Pathology, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, 150 Ximen Street, Linhai, Zhejiang, China
| | - Yu Zhang
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Shaoxing University, Shaoxing, Zhejiang, China.
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, 150 Ximen Street, Linhai, Zhejiang, China.
- Zhejiang Provincial Clinical Research Center for Digestive Diseases, Linhai, Zhejiang Province, China.
- Zhejiang Clinovation Pride, Linhai, Zhejiang Province, China.
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Heo S, Huh J, Kim JK, Lee KM. Delayed Perforation After Endoscopic Resection of Upper Gastrointestinal Tumors: CT Findings to Identify Patients Requiring Surgery. J Clin Gastroenterol 2024:00004836-990000000-00308. [PMID: 38896425 DOI: 10.1097/mcg.0000000000002037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE To determine the clinical and imaging factors associated with surgical treatment in patients with delayed perforation after endoscopic resection of upper gastrointestinal tumors. METHODS We retrospectively included patients with delayed perforation after endoscopic tumor resection for gastric or duodenal tumors between January 2007 and December 2021 in a tertiary hospital. We compared the clinical, endoscopic, and CT findings of the surgical and conservative treatment groups. Univariable and multivariable analyses were performed to identify significant factors associated with surgery. RESULTS Among 10,423 patients who had undergone endoscopic tumor resection, 52 (0.50%) experienced delayed perforation, with 20 patients (35.5%) treated surgically and 32 patients (64.5%) treated conservatively. The CT findings of gross perforation (adjusted odds ratio [OR]=6.75, 95% confidence interval [CI], 1.04-43.89; P=0.045) and presence of peritonitis (OR=34.26, 95% CI, 5.52-212.50; P<0.001) were significantly associated with surgical treatment. Other clinical factors as well as CT-measured amount of pneumoperitoneum were not significant factors. CONCLUSIONS CT findings of gross perforation and peritonitis are significant factors associated with surgery in delayed perforation after endoscopic tumor resection. These factors can aid in guiding the patients towards an appropriate treatment plan.
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Affiliation(s)
- Subin Heo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul
| | - Jimi Huh
- Department of Radiology, Ajou University Hospital, Ajou University School of Medicine, Yeongtong-gu, Suwon
| | - Jai Keun Kim
- Department of Radiology, Ajou University Hospital, Ajou University School of Medicine, Yeongtong-gu, Suwon
| | - Ki Myung Lee
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Yeongtong-gu, Suwon, Republic of Korea
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Ueda T, Ishihara R, Yoshii S, Li JW, Asada Y, Kitagawa D, Kizawa A, Ninomiya T, Okubo Y, Kawakami Y, Tani Y, Shichijo S, Kanesaka T, Yamamoto S, Takeuchi Y, Higashino K, Uedo N, Michida T. Predictors of technical difficulty for trainees in esophageal endoscopic submucosal dissection. Esophagus 2024; 21:58-66. [PMID: 38082187 DOI: 10.1007/s10388-023-01028-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/03/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Esophageal endoscopic submucosal dissection (ESD) is technically challenging, especially for trainees, and requires a safe training system. This study aimed to identify predictors of technical difficulty facing trainees performing esophageal ESD to establish such system. METHODS This was a single-center retrospective study of patients with esophageal cancer who underwent ESD performed by trainees between January 2010 and August 2022. Technical difficulties were defined as muscularis propria exposure and long procedure time (≥ 90 min). Factors associated with these technical difficulties were investigated. RESULTS A total of 798 lesions in 721 patients were evaluated. Muscularis propria exposure occurred in 298 lesions (37.3%), including 10 perforations (1.3%). The procedure time was ≥ 90 min in 134 lesions (16.8%). In the multivariate analysis, tumor size ≥ 20 mm, tumors ≥ 1/2 of the circumference, and those close to previous treatment scars significantly increased the incidence of both difficulties, whereas tumors in the upper esophagus significantly decreased this incidence. Furthermore, female sex and tumors in the left wall were independent predictors of muscularis propria exposure, and elevated morphology was an independent predictor of long procedure time. Muscularis propria exposure and long procedure time occurred in more than half of the cases with three or more predictors of each difficulty. CONCLUSIONS Large tumors and tumors close to previous treatment scars increase technical difficulties for trainees in esophageal ESD. Conversely, tumors in the upper esophagus reduce these difficulties. These results enable us to predict the difficulty level preoperatively and select appropriate cases in stepwise training.
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Affiliation(s)
- Tomoya Ueda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan.
| | - Shunsuke Yoshii
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - James Weiquan Li
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Yuya Asada
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Daiki Kitagawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Atsuko Kizawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Takehiro Ninomiya
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Yuki Okubo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Yushi Kawakami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Yasuhiro Tani
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
| | - Tomoki Michida
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-Ku, Osaka, 541-8567, Japan
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Okubo Y, Ishihara R. Endoscopic Submucosal Dissection for Esophageal Cancer: Current and Future. Life (Basel) 2023; 13:life13040892. [PMID: 37109421 PMCID: PMC10140872 DOI: 10.3390/life13040892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/06/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been widely used to treat superficial esophageal cancer. The advantages of esophageal ESD include a high en bloc resection rate and accurate pathological diagnosis. It enables local resection of the primary tumor and accurate identification of the risk factors for lymph node metastasis, including depth, vascular invasion, and types of invasion. Even in cases with clinical T1b-SM cancer, ESD and additional treatment can achieve radical cure, depending on the risk of lymph node metastasis. Esophageal ESD will be increasingly vital in minimally invasive and effective esophageal cancer treatment. This article describes the current status and prospects of esophageal ESD.
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Yamaguchi H, Fukuzawa M, Kawai T, Uchida K, Koyama Y, Madarame A, Morise T, Sugimoto A, Kono S, Naito S, Itoi T. Efficacy of endoscopic clip closure for nonperforated muscle layer exposure during esophageal endoscopic submucosal dissection. Dis Esophagus 2022; 35:6537048. [PMID: 35217865 DOI: 10.1093/dote/doac009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/10/2021] [Indexed: 12/11/2022]
Abstract
Exposure of the muscle layer during endoscopic submucosal dissection (ESD) in the esophagus can lead to complications such as fever and pain. Although closure with endoscopic clips is widely used when perforation is a major complication, its value when the exposed muscle layer is not perforated is unclear. Data for 104 lesions in 104 patients who underwent esophageal ESD between 2008 and 2020 were retrospectively analyzed. Patients with multiple tumors, those who experienced procedure-related adverse events such as aspiration pneumonitis, perforation during ESD, or delayed bleeding, and those in whom the muscle layer was not exposed were excluded. The clinical course of inflammation after ESD in patients in whom the muscle layer was exposed was examined according to whether endoscopic clips were used for closure. A significantly greater number of patients had a temperature ≤ 37.5°C in the clip closure group than in the nonclip closure group (≤37.5°C/≥37.6°C, 47/14 vs. 25/18, respectively, P = 0.040). Furthermore, significantly more patients in the clip closure group had a white blood cell count ≤10,000/μL (≤10,000/μL/>10,000/μL, 51/10 vs. 21/22, P < 0.001) and a C-reactive protein level < 1.0 mg/dL (<1.0 mg/dL/≥1.0 mg/dL, 40/21 vs. 36/7, P = 0.040) in the 24 hour post-ESD. The results were not changed after propensity score matching. Closure with endoscopic clips reduces inflammation after esophageal ESD with nonperforated muscle layer exposure. Even if there is no obvious perforation during ESD, closure of the exposed muscle layer with endoscopic clips may contribute to the clinical course post-ESD.
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Affiliation(s)
- Hayato Yamaguchi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Kawai
- Endoscopy Center, Tokyo Medical University Hospital, Tokyo, Japan
| | - Kumiko Uchida
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yohei Koyama
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Akira Madarame
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Morise
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Sugimoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shin Kono
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Sakiko Naito
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Bertrand G, Rivory J, Robert M, Saurin JC, Pelascini É, Monneuse O, Gruner L, Poncet G, Valette PJ, Gimonet H, Rostain F, Ber CÉ, Bouffard Y, Boibieux A, Ciochina M, Landel V, Boyer H, Jacques J, Ponchon T, Pioche M. Digestive perforations related to endoscopy procedures: a local management charter based on local evidence and experts' opinion. Endosc Int Open 2022; 10:E328-E341. [PMID: 35433214 PMCID: PMC9010098 DOI: 10.1055/a-1783-8424] [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: 03/18/2021] [Accepted: 10/28/2021] [Indexed: 11/06/2022] Open
Abstract
Background and study aims Perforations are a known adverse event of endoscopy procedures; a proposal for appropriate management should be available in each center as recommended by the European Society of Gastrointestinal Endoscopy. The objective of this study was to establish a charter for the management of endoscopic perforations, based on local evidence. Patients and methods Patients were included if they experienced partial or complete perforation during an endoscopic procedure between 2008 and 2018 (retrospectively until 2016, then prospectively). Perforations (size, location, closure) and management (imagery, antibiotics, surgery) were analyzed. Using these results, a panel of experts was asked to propose a consensual management charter. Results A total of 105 patients were included. Perforations occurred mainly during therapeutic procedures (91, 86.7%). Of the perforations, 78 (74.3 %) were diagnosed immediately and managed during the procedure; 69 of 78 (88.5 %) were successfully closed. Closures were more effective during therapeutic procedures (60 of 66, 90.9 %) than during diagnostic procedures (9 of 12, 75.0 %, P = 0.06). Endoscopic closure was effective for 37 of 38 perforations (97.4 %) < 0.5 cm, and for 26 of 34 perforations (76.5 %) ≥ 0.5 cm ( P < 0.05). For perforations < 0.5 cm, systematic computed tomography (CT) scan, antibiotics, or surgical evaluation did not improve the outcome. Four of 105 deaths (3.8 %) occurred after perforation, one of which was attributable to the perforation itself. Conclusions Detection and closure of perforations during endoscopic procedure had a better outcome compared to delayed perforations; perforations < 0.5 cm had a very good prognosis and CT scan, surgeon evaluation, or antibiotics are probably not necessary when the endoscopic closure is confidently performed. This work led to proposal of a local management charter.
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Affiliation(s)
- Gaspard Bertrand
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France
| | - Jérôme Rivory
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France
| | - Maud Robert
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive Hépatobiliaire, Lyon, France
| | - Jean-Christophe Saurin
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France
| | - Élise Pelascini
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive Hépatobiliaire, Lyon, France
| | - Olivier Monneuse
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive d’Urgence, Lyon, France
| | - Laurent Gruner
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive d’Urgence, Lyon, France
| | - Gilles Poncet
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Chirurgie Digestive Hépatobiliaire, Lyon, France
| | - Pierre-Jean Valette
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Radiologie, Lyon France
| | - Hélène Gimonet
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Radiologie, Lyon France
| | - Florian Rostain
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France
| | - Charles-Éric Ber
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Anesthésie, Section Endoscopie, Lyon, France
| | - Yves Bouffard
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Anesthésie, Section Endoscopie, Lyon, France
| | - André Boibieux
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service de Pathologies Infectieuses, Lyon, France
| | - Marina Ciochina
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France
| | - Verena Landel
- Hospices Civils de Lyon, Direction de la Recherche Clinique et de l’Innovation, Lyon, France
| | - Hélène Boyer
- Hospices Civils de Lyon, Direction de la Recherche Clinique et de l’Innovation, Lyon, France
| | - Jérémie Jacques
- Hôpital Dupuytren, Service de Gastroentérologie, Limoges, France
| | - Thierry Ponchon
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France,Hôpital Dupuytren, Service de Gastroentérologie, Limoges, France
| | - Mathieu Pioche
- Hospices Civils de Lyon, Hôpital Édouard Herriot, Service d’Hépato-gastroentérologie, Lyon, France
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7
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Sun D, Shi Q, Qi Z, Li B, Cai S, Zhou P, Zhong Y. Simultaneous endoscopic submucosal dissection for synchronous multiple early esophageal squamous cell carcinoma: a propensity score-matched analysis. Surg Endosc 2022; 36:109-116. [PMID: 33416991 DOI: 10.1007/s00464-020-08243-7] [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] [Received: 06/15/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The clinical effect of endoscopic submucosal dissection (ESD) in the treatment of early esophageal squamous cell carcinoma (EESCC) is widely recognized. However, the long-term treatment outcome of simultaneous ESD for multiple EESCC currently remained unknown. Hence, this study was aimed at further evaluating the long-term outcome of simultaneous ESD for synchronous multiple EESCC by comparing with ESD for single EESCC. METHODS Consecutive patients who underwent ESD for EESCC from June 2008 to June 2018 were included. Propensity score-matched analysis was used to compensate for the differences in age, sex, tumor location, tumor size, and tumor invasion depth between simultaneous and single ESD groups. Treatment outcomes including en bloc resection rate, curative resection rate, complication rate, and long-term outcomes including overall survival (OS), recurrence-free survival (RFS), metachronous recurrence were compared between the 2 groups after matching. RESULTS The propensity score-matched analysis included 332 lesions (166 patients) and 332 lesions (332 patients) in simultaneous and single ESD groups, respectively. Among all the outcomes, en bloc resection, curative resection, 5-year OS, and 5-year RFS rates were comparable. Complications were more common in the simultaneous ESD group (15.06% vs. 9.64%, P = 0.073). The 5-year metachronous recurrence rates were significantly high in the simultaneous ESD groups (24.28% vs. 6.99%). CONCLUSIONS Simultaneous ESD is an effective and safe methodology for synchronous multiple EESCC; it also reduces hospital stay and medical expenses. The risk of metachronous recurrence is higher for patients with synchronous multiple EESCC; thus, more intensive strategies are required.
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Affiliation(s)
- Di Sun
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China
| | - Qiang Shi
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China
| | - ZhiPeng Qi
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China
| | - Bing Li
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China
| | - Shilun Cai
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China
| | - Pinghong Zhou
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China.
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China.
| | - Yunshi Zhong
- Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, 200032, China.
- Endoscopy Research Institute of Fudan University, Shanghai, 200032, China.
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8
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Successful Recanalization of a Long-Segment Complete Esophageal Stricture Using Endoscopic and Fluoroscopic Techniques. ACG Case Rep J 2019; 6:00130. [PMID: 31620510 PMCID: PMC6722373 DOI: 10.14309/crj.0000000000000130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/24/2019] [Indexed: 12/21/2022] Open
Abstract
Complete esophageal strictures are rare complications in patients who have received head and neck radiation therapy. Although mild strictures are generally amenable to dilation or stenting, management of these debilitating strictures is not well established. Treatment of long-segment obstructions is particularly complicated because documented techniques generally apply for strictures up to 3 cm in length. This report describes a successful recanalization of a long-segment complete esophageal stricture using combined antegrade-retrograde endoscopic therapy with adjunctive fluoroscopic techniques.
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Kim GE, Kim DK, Choi JW, Chung IS, Jung DW. The safety of endoscopic esophageal procedures under general anesthesia. Korean J Anesthesiol 2017; 70:555-560. [PMID: 29046776 PMCID: PMC5645589 DOI: 10.4097/kjae.2017.70.5.555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/01/2017] [Accepted: 04/03/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND With the increasing demand for general anesthesia for endoscopic esophageal procedures, anesthesiologists should understand the clinical characteristics of post-procedural complications (PPCs). METHODS We retrospectively investigated the incidence of and risk factors associated with PPCs of endoscopic esophageal procedures performed under general anesthesia from July 2013 to November 2016. The final analysis included 129 patients; 114 who underwent esophageal endoscopic dissection for esophageal tumors and 15 cases of peroral endoscopic myotomy for achalasia. Frank perforation during the procedure was defined as an endoscopically recognizable or clinically detected perforation during the procedures. A multivariable logistic regression analysis was conducted to identify independent risk factors for PPCs. RESULTS The overall incidence of PPCs was 19.4% (25/129). All of the PPCs were managed successfully with conservative measures. The most common PPC was symptomatic, radiologically documented atelectasis (11/25, 44.0%), followed by esophageal perforation-related PPCs (symptomatic pneumomediastinum or pneumoperitoneum; 9/25, 36.0%). In the multivariable analysis, frank perforation during the procedure was the only independent risk factor for PPCs (odds ratio, 8.470, 95% CI, 2.051-34.974, P = 0.003). Although frank perforation during the procedure occurred in 13 patients, 38.5% (5/13) of them did not develop any clinical sequelae after their procedures. Compared with patients without PPCs, patients who developed PPCs took longer to their first oral intake and had prolonged hospital stays (P = 0.047 and 0.026, respectively). CONCLUSIONS Iatrogenic perforation during endoscopic esophageal procedures under general anesthesia was the only independent risk factor for PPCs; therefore, proactive measures and close follow-up are necessary.
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Affiliation(s)
- Go Eun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Sun Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Da Woon Jung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Tsujii Y, Hayashi Y, Kawai N, Yamada T, Yamamoto K, Hayashi S, Yoshii S, Nagai K, Inoue T, Nishida T, Iijima H, Mita E, Inoue A, Takehara T. Risk of perforation in balloon dilation associated with steroid injection for preventing esophageal stricture after endoscopic submucosal dissection. Endosc Int Open 2017; 5:E573-E579. [PMID: 28670613 PMCID: PMC5482748 DOI: 10.1055/s-0043-110077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic local steroid injection (LSI) has been used to prevent esophageal strictures after endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms (SENs). This study aimed to evaluate the safety and efficacy of LSI therapy. PATIENTS AND METHODS From May 2007 to September 2014, at four institutions, 40 consecutive patients with SENs were treated with ESD that left a mucosal defect of more than three-quarters of the esophageal circumference. Two patients who underwent esophagectomy after ESD were excluded, and 38 patients were analyzed. The incidence of post-ESD strictures and adverse events associated with LSI were retrospectively investigated. RESULTS Prophylactic LSI was administered in 28 patients (LSI group), and not administered in 10 patients (Non-prevention group). Post-ESD stricture rates were significantly lower in the LSI group (43 %) than in the Non-prevention group (90 %) ( P = 0.012). Endoscopic balloon dilation (EBD) was conducted in 11 patients (39 %) in the LSI group and in 7 (70 %) in the Non-prevention group. In the LSI group, perforation caused by EBD occurred in five patients, while in the Non-prevention group, it occurred in only one patient who had received subsequent LSI before the perforation. Four patients with perforation successfully recovered after conservative therapy, but the other two patients required surgical treatment. A review of follow-up examinations with endoscopic ultrasonography and narrow-band imaging showed impaired ulcer-healing process after LSI. CONCLUSION LSI is useful for preventing post-ESD strictures, but it appears to increase the risk of perforation in cases of EBD.
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Affiliation(s)
- Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Naoki Kawai
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan,Department of Gastroenterology, Osaka Hospital, Japan Community Health Care Organization, Osaka, Japan
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Shunsuke Yoshii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kengo Nagai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuya Inoue
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Eiji Mita
- Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Atsuo Inoue
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Corresponding author Tetsuo Takehara, MD PhD Department of Gastroenterology and HepatologyOsaka University Graduate School of Medicine2-2 YamadaokaSuitaOsaka 565-0871Japan+81-6-6879-3629
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Libânio D, Pimentel-Nunes P, Dinis-Ribeiro M. Complications of endoscopic resection techniques for upper GI tract lesions. Best Pract Res Clin Gastroenterol 2016; 30:735-748. [PMID: 27931633 DOI: 10.1016/j.bpg.2016.09.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 02/09/2023]
Abstract
Adverse events can occur during and after the endoscopic resection of upper gastrointestinal lesions. Their incidence can be minimized through the adoption of preventive measures and their final outcomes can be optimized through prompt identification and adequate treatment. In this evidence-based review we describe the risk factors for adverse events, preventive measures to avoid them and their management when they occur. Algorithms of action are also provided. Oesophageal strictures can be prevented with corticosteroids (either locally injected or systemically administered) and treated with endoscopic dilatation. Bleeding can be minimized through the adoption of prophylactic coagulation and novel preventive measures are emerging and being evaluated. Bleeding management includes coagulation therapy, clips and haemostatic powders. Perforations can nowadays be successfully treated endoscopically in the majority of the cases and conservative treatment is associated with favourable outcomes although optimal management is unclear.
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Affiliation(s)
- D Libânio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.
| | - P Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal; CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
| | - M Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal; CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
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Maeda Y, Hirasawa D, Fujita N, Ohira T, Harada Y, Yamagata T, Koike Y, Suzuki K. Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema: A randomized, double-blind, controlled trial. World J Gastroenterol 2016; 22:7373-7382. [PMID: 27621583 PMCID: PMC4997641 DOI: 10.3748/wjg.v22.i32.7373] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/27/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the efficacy of CO2 insufflation for reduction of mediastinal emphysema (ME) immediately after endoscopic submucosal dissection (ESD).
METHODS A total of 46 patients who were to undergo esophageal ESD were randomly assigned to receive either CO2 insufflation (CO2 group, n = 24) or air insufflation (Air group, n = 22). Computed tomography (CT) was carried out immediately after ESD and the next morning. Pain and abdominal distention were chronologically recorded using a 100-mm visual analogue scale (VAS). The volume of residual gas in the digestive tract was measured using CT imaging.
RESULTS The incidence of ME immediately after ESD in the CO2 group was significantly lower than that in the Air group (17% vs 55%, P = 0.012). The incidence of ME the next morning was 8.3% vs 32% respectively (P = 0.066). There were no differences in pain scores or distention scores at any post-procedure time points. The volume of residual gas in the digestive tract immediately after ESD was significantly smaller in the CO2 group than that in the Air group (808 mL vs 1173 mL, P = 0.013).
CONCLUSION CO2 insufflation during esophageal ESD significantly reduced postprocedural ME. CO2 insufflation also reduced the volume of residual gas in the digestive tract immediately after ESD, but not the VAS scores of pain and distention.
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Kawata N, Tanaka M, Kakushima N, Takizawa K, Imai K, Hotta K, Matsubayashi H, Tsukahara M, Kawamura I, Kurai H, Ono H. The low incidence of bacteremia after esophageal endoscopic submucosal dissection (ESD) obviates the need for prophylactic antibiotics in esophageal ESD. Surg Endosc 2016; 30:5084-5090. [PMID: 26983438 DOI: 10.1007/s00464-016-4857-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 03/03/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although a high incidence of bacteremia after esophageal endoscopic procedures has been reported, the incidence of bacteremia associated with esophageal endoscopic submucosal dissection (ESD) remains unknown. Therefore, we investigated the incidence of bacteremia associated with esophageal ESD. METHODS From April 2013 to March 2014, patients who underwent esophageal ESD were enrolled prospectively. Two sets of blood cultures were collected from patients at the following time points: (1) immediately after ESD; (2) the next morning; and (3) when fever ≥38 °C was present after ESD. RESULTS A total of 424 blood culture sets were collected from 101 patients. Six patients had positive blood cultures immediately after ESD (4 %, 7/202 sets). Another patient had a positive blood culture the next morning (0.5 %, 1/202 sets). Ten patients (10 %) developed a post-ESD fever ≥38 °C, and blood cultures from these patients were all negative (0/20 sets). The seven patients with positive blood cultures had no post-ESD fever or infectious symptoms. Growth of Bacteroides thetaiotaomicron was only observed in one patient (1 %) with positive blood cultures immediately after ESD, and this patient was diagnosed with transient bacteremia. The other six patients were considered to have contaminants in their blood cultures. Thus, the incidence of bacteremia after esophageal ESD was 1 % [95 % confidence interval (CI) 0-5 %]. No patient had infectious symptoms, and none required antibiotics after ESD. CONCLUSIONS The incidence of bacteremia after esophageal ESD was low and post-ESD fever was not associated with bacteremia. We conclude that use of routine prophylactic antibiotics to patients undergoing esophageal ESD is unnecessary. CLINICAL TRIAL REGISTRY NUMBER UMIN000012908.
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Affiliation(s)
- Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Mika Tsukahara
- Division of Infectious Diseases, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Ichiro Kawamura
- Division of Infectious Diseases, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hanako Kurai
- Division of Infectious Diseases, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Maselli R, Santi G. Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc 2016; 8:86-103. [PMID: 26839649 PMCID: PMC4724034 DOI: 10.4253/wjge.v8.i2.86] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/19/2015] [Accepted: 11/24/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.
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Repici A, Zullo A, Anderloni A, Hassan C. Endoscopic Management of Procedure-Related Bleeding and Perforation. GI ENDOSCOPIC EMERGENCIES 2016:257-276. [DOI: 10.1007/978-1-4939-3085-2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Yang S, Zeng MS, Zhang ZY, Zhang HL, Liang L, Zhang XW. Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications? Acta Radiol 2015; 56:1216-21. [PMID: 25277388 DOI: 10.1177/0284185114551399] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Many of the acute alterations after peroral endoscopic myotomy (POEM) may be of little clinical significance, while others may herald major clinical problems. The question whether pneumomediastinum/pneumoperitoneum is a normal postoperative finding after POEM, or should be regarded as a sign of a complication needs to be evaluated. Familiarity with these findings in computed tomography (CT) is essential for radiologists. PURPOSE To evaluate whether or not pneumomediastinum/pneumoperitoneum detected by chest CT is a sign of a complication after POEM using CO2 insufflation for esophageal achalasia. MATERIAL AND METHODS One hundred and eight patients with esophageal achalasia who underwent chest CT within 30 hours after POEM were included. CT findings were retrospectively reviewed by two radiologists in consensus. The correlation between pneumomediastinum and/or pneumoperitoneum shown on CT and the development of complications was analyzed. RESULTS Abnormal findings were identified on post-treatment CT, including pneumomediastinum and/or pneumoperitoneum (53.7%, 58/108), pneumothorax (0.9%, 1/108), subcutaneous emphysema (29.6%, 32/108), pleural effusion (69.4%, 75/108), segmental atelectasis of lung tissue (29.6%, 32/108), minor inflammation of lungs (69.4%, 75/108), and ascites (0.9%, 1/108). Pneumomediastinum and pneumoperitoneum were observed simultaneously in 29 cases. The incidence rate of mild complications was high (79.6%, 86/108), while the rate of severe complications was low (2.8%, 3/108). There was no significant correlation between the occurrence of pneumomediastinum and/or pneumoperitoneum on CT and the development of complications (P = 0.542), or the development of severe complications including delayed hemorrhage, esophageal perforation, and retroperitoneal abscess. CONCLUSION Pneumomediastinum and pneumoperitoneum detected by CT occur frequently after POEM and may be regarded as normal postoperative changes.
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Affiliation(s)
- Shan Yang
- Department of Radiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Medical Imaging; Department of Medical Imaging, Shanghai Medical College, Fudan Unversity, Shanghai, PR China
| | - Meng-su Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Medical Imaging; Department of Medical Imaging, Shanghai Medical College, Fudan Unversity, Shanghai, PR China
| | - Zhi-yong Zhang
- Department of Radiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Medical Imaging; Department of Medical Imaging, Shanghai Medical College, Fudan Unversity, Shanghai, PR China
| | - Hao-ling Zhang
- Department of Radiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Medical Imaging; Department of Medical Imaging, Shanghai Medical College, Fudan Unversity, Shanghai, PR China
| | - Liang Liang
- Department of Radiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Medical Imaging; Department of Medical Imaging, Shanghai Medical College, Fudan Unversity, Shanghai, PR China
| | - Xing-wei Zhang
- Department of Radiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Medical Imaging; Department of Medical Imaging, Shanghai Medical College, Fudan Unversity, Shanghai, PR China
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Abstract
Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.
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Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection for Endoscopic Therapy of Barrett's Esophagus-related Neoplasia. Gastroenterol Clin North Am 2015; 44:317-35. [PMID: 26021197 DOI: 10.1016/j.gtc.2015.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A major paradigm shift has occurred in the management of dysplastic Barrett's esophagus (BE) and early esophageal carcinoma. Endoscopic therapy has now emerged as the standard of care for this disease entity. Endoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection combined with ablation techniques help achieve long-term curative success comparable with surgical outcomes, in this subgroup of patients. This article is an in-depth review of these endoscopic resection techniques, highlighting their role and value in the overall management of BE-related dysplasia and neoplasia.
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Cai MY, Zhou PH, Yao LQ, Zhu BQ, Liang L, Li QL. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014; 80:1046-55. [PMID: 24998467 DOI: 10.1016/j.gie.2014.05.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 05/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a promising new endoscopic method for the treatment of achalasia. OBJECTIVE The aim of this study was to analyze the value of routine postoperative CT of the chest to detect POEM-associated adverse events. DESIGN Single-center, retrospective study. SETTING Tertiary care center. PATIENTS AND INTERVENTIONS Between August 2010 and July 2012, 428 patients underwent POEM. Three hundred postprocedure CT POEM patients were retrospectively analyzed and findings correlated with clinical outcome and management. MAIN OUTCOME MEASUREMENTS The frequency of postoperative pathological CT scan findings after POEM and the rate of interventions required for adverse event management. RESULTS The main CT findings could be divided into frequent and reversible sequelae of POEM, pneumomediastinum (48%), pneumoperitoneum (37%), and subcutaneous emphysema (28%), and into potential adverse events such as pneumothorax (17%), pleural effusion (66%), pneumonitis (52%), and focal atelectasis (21%). Only 17 of 50 patients with pneumothorax (5.6% of all patients) and 2 of 200 patients with pleural effusion (0.7% of all patients) required interventional treatment based on clinical symptoms. In 1 patient, a hematoma was observed on a CT scan before any clinical manifestation occurred. Increasing age and the use of air instead of CO2 were associated with an increased rate of pneumothorax (P = .031; 95% confidence interval, 1.002-1.049 and P < .001; 95% confidence interval, 0.012-0.157, respectively). LIMITATIONS Single-center, retrospective study. CONCLUSIONS Routine chest CT scan for achalasia patients undergoing POEM is probably not warranted because of the high rate of minor and clinically irrelevant findings. The use of CO2 is obligatory to reduce related adverse events.
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Affiliation(s)
- Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bo-Qun Zhu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liang Liang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Hammad H, Kaltenbach T, Soetikno R. Endoscopic submucosal dissection for malignant esophageal lesions. Curr Gastroenterol Rep 2014; 16:386. [PMID: 24659252 DOI: 10.1007/s11894-014-0386-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of esophageal cancer has been increasing while the prognosis remains very poor. Endoscopic submucosal dissection (ESD) was developed in Japan for en bloc resection of early gastric cancer with excellent results. The use of ESD in early squamous cell cancer (SCC) of the esophagus in Japan has been increasing with long-term results comparable to those in early gastric cancer. The use of ESD in Barrett's neoplasia in western countries has been challenged by the low complete resection rates and the risk of metachronous lesions from surrounding non-dysplastic Barrett's epithelium. Efforts to combine ESD with other treatment modalities such as radiofrequency ablation in Barrett's neoplasia and chemoradiation in SCC appear to be promising. The use of steroid therapy (local or systemic) has been demonstrated to prevent post-ESD stenosis, which is the most common complication after esophageal ESD.
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Affiliation(s)
- Hazem Hammad
- Harry S. Truman Memorial Veterans Hospital, University of Missouri Hospital and Clinics, Columbia, MO, USA,
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Kim JS, Kim BW, Shin IS. Efficacy and safety of endoscopic submucosal dissection for superficial squamous esophageal neoplasia: a meta-analysis. Dig Dis Sci 2014; 59:1862-1869. [PMID: 24619279 DOI: 10.1007/s10620-014-3098-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 02/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Although endoscopic submucosal dissection (ESD) has grown popular in resecting lesions in the stomach, the application of ESD to the esophagus has been limited by greater technical difficulty. An increasing number of series have recently reported the application of ESD to esophageal lesions. The aim of the present systemic review and meta-analysis was to evaluate the efficacy and safety of ESD for esophageal lesions. METHODS Comprehensive literature searches (1999-2012) were performed on studies that reported ESD for the removal of esophageal neoplasia. Primary outcome measures were pooled estimates of complete resection rate and en bloc resection rate. Secondary outcome measures were pooled estimates of complication rates. RESULTS A total of 15 studies provided data on 776 ESD-treated lesions. The pooled estimate of complete resection rate was 89.4% (95% CI 86.2-91.9%). The pooled estimate of en bloc resection was 95.1% (95% CI 92.6-96.8%). The pooled estimates of complications of ESD such as bleeding, perforation, and stenosis were 2.1, 5.0, and 11.6%, respectively. CONCLUSIONS ESD appeared to be an extremely effective technique to achieve complete resection of esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach.
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Affiliation(s)
- Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, 665, Bupyeong-dong, Bupyeong-gu, Inchon, 403-720, Republic of Korea
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Rolanda C, Caetano AC, Dinis-Ribeiro M. Emergencies after endoscopic procedures. Best Pract Res Clin Gastroenterol 2013; 27:783-98. [PMID: 24160934 DOI: 10.1016/j.bpg.2013.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 07/25/2013] [Accepted: 08/11/2013] [Indexed: 02/08/2023]
Abstract
Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.
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Affiliation(s)
- Carla Rolanda
- Department of Gastroenterology, Hospital Braga, 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/Guimarães, Portugal.
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Haidry RJ, Butt MA, Dunn J, Banks M, Gupta A, Smart H, Bhandari P, Smith LA, Willert R, Fullarton G, John M, Pietro MD, Penman I, Novelli M, Lovat LB. Radiofrequency ablation for early oesophageal squamous neoplasia: Outcomes form United Kingdom registry. World J Gastroenterol 2013; 19:6011-6019. [PMID: 24106401 PMCID: PMC3785622 DOI: 10.3748/wjg.v19.i36.6011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 07/12/2013] [Accepted: 07/25/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To report outcomes on patients undergoing radiofrequency ablation (RFA) for early oesophageal squamous neoplasia from a National Registry.
METHODS: A Prospective cohort study from 8 tertiary referral centres in the United Kingdom. Patients with squamous high grade dysplasia (HGD) and early squamous cell carcinoma (ESCC) confined to the mucosa were treated. Visible lesions were removed by endoscopic mucosal resection (EMR) before RFA. Following initial RFA treatment, patients were followed up 3 monthly. Residual flat dysplasia was treated with RFA until complete reversal dysplasia (CR-D) was achieved or progression to invasive Squamous cell cancer defined as infiltration into the submucosa layer or beyond. The main outcome measures were CR-D at 12 mo from start of treatment, long term durability, progression to cancer and adverse events.
RESULTS: Twenty patients with squamous HGD/ESCC completed treatment protocol. Five patients (25%) had EMR before starting RFA treatment. CR-D was 50% at 12 mo with a median of 1 RFA treatment, mean 1.5 (range 1-3). Two further patients achieved CR-D with repeat RFA after this time. Eighty per cent with CR-D remain dysplasia free at latest biopsy, with median follow up 24 mo (IQR 17-54). Six of 20 patients (30%) progressed to invasive cancer at 1 year. Four patients (20%) required endoscopic dilatations for symptomatic structuring after treatment. Two of these patients have required serial dilatations thereafter for symptomatic dysphagia with a median of 4 dilatations per patient. The other 2 patients required only a single dilatation to achieve an adequate symptomatic response. One patient developed cancer during follow up after end of treatment protocol.
CONCLUSION: The role of RFA in these patients remains unclear. In our series 50% patients responded at 12 mo. These figures are lower than limited published data.
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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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Sato H, Inoue H, Ikeda H, Grace R Santi E, Yoshida A, Onimaru M, Kudo S. Clinical experience of esophageal perforation occurring with endoscopic submucosal dissection. Dis Esophagus 2013; 27:617-22. [PMID: 23980646 DOI: 10.1111/dote.12125] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal perforation occurring during or after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is a rare, but serious complication. However, reports of its characteristics, including endoscopic imaging and management, have not been fully detailed. To analyze and report the clinical presentation and management of esophageal perforations occurred during or after EMR/ESD. Four hundred seventy-two esophageal neoplasms in 368 patients were treated (171 EMR; ESD 306) at Northern Yokohama Hospital from 2003 to 2012. Esophageal perforation occurred in a total of seven (1.9%) patients, all of whom were male and had undergone ESD. The etiology of perforation was: three (42.9%) intraoperative; three (42.9%) balloon dilatation for stricture prevention; one (14.2%) due to food bolus impaction. All cases were managed non-operatively based on the comprehensive assessment of clinical severity, extent of the injury, and the time interval from perforation to treatment onset. Conservative management included (i) bed rest and continuous monitoring to determine the need for operative intervention; (ii) fasting and intravenous fluid infusion/ tube feeding; and (iii) intravenous antibiotics. All defects closed spontaneously, save one case where closure was achieved by endoscopic clipping. Surgery was not required. Conservative management for esophageal perforation during advanced endoscopic resection is may be possible when there is no delay in diagnosis or treatment. Decision-making should be governed purely by multidisciplinary discussion.
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Affiliation(s)
- H Sato
- Digestive Disease Center, Northern Yokohama Hospital, Showa University, Yokohama, Japan
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27
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Liu BR, Song JT, Kong LJ, Pei FH, Wang XH, Du YJ. Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia. Surg Endosc 2013; 27:4354-9. [PMID: 23765425 DOI: 10.1007/s00464-013-3023-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 05/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection of esophageal or cardial subepithelial tumors (SETs) originating from the muscularis propria (MP) is rarely done due to the high risk of perforation, fistula formation, and secondary infection. The aim of this study was to evaluate the preliminary clinical feasibility and safety of tunneling endoscopic muscularis dissection (tEMD) for resection of SETs located in the esophagus and gastric cardia METHODS Twelve patients with SETs originating from the MP of the esophagus (n = 7) or cardia (n = 5) were treated by tEMD. The procedure included creation of a submucosal tunnel to reach the tumor, dissection of the tumor from the surrounding submucosal tissue and the unaffected MP layer, full-thickness resection of the tumor and affected MP, and subsequent closure of the tunnel mucosal entry with endoscopic clips. RESULTS The en bloc resection rate was 100 % (seven lesions affected the deep MP so complete MP resection was performed; five lesions affected the superficial MP for a partial MP resection). The average tumor size was 18.5 ± 6.9 (range 10-30) mm. The mean operating time was 78.3 ± 25.5 (range 50-130) min. The histological diagnoses were two gastrointestinal stromal tumors with very low risk, nine leiomyomas, and one schwannoma. Air leakage and effusion included subcutaneous and mediastinal emphysema in eight patients (66.7 %), pneumothorax in four (33.3 %), pneumoperitoneum in three (25.0 %), and small pleural effusion in two (16.7 %). All air leakage and effusion cases were resolved with conservative management. No patient developed delayed hemorrhage and chronic fistula after tEMD. During the mean follow-up time of 7.1 ± 4.3 (range 2-15) months, no tumor recurrence was found in any patient. CONCLUSIONS tEMD appears to be a feasible minimally invasive and effective treatment for patients with SETs originating from the MP layer of the esophagus and cardia.
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Affiliation(s)
- Bing-Rong Liu
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin, 150086, People's Republic of China,
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Ge N, Sun S, Wang S, Liu X, Wang G, Guo J. Endoscopic Ultrasound-Assisted Tunnel-Type Endoscopic Submucosal Dissection for the Treatment of Esophageal Tumors Arising in the Muscularis Propria (with video). Endosc Ultrasound 2013; 2:11-15. [PMID: 24949361 PMCID: PMC4062232 DOI: 10.7178/eus.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 01/29/2013] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Esophageal tumors arising in the muscularis propria are difficult to be resected endoscopically using standard electro-surgical techniques, even the endoscopic submucosal dissection (ESD) technique appeared recently. Our purpose is to investigate the efficacy of endoscopic ultrasound (EUS)-assisted tunnel-type ESD for resection of these tumors. METHODS A total of 17 patients were included in this study. A standard endoscope was used. The submucosal tunnel was created with the triangle knife according to the standard ESD technique, about 5 cm proximal to the lesion. EUS was performed within the tunnel to detect the tumor, and then the tumor was separated both from the submucosal and the muscle layers. After the tumor was removed, several clips were used to close the mucosal defect. EUS was performed to evaluate the healing quality 1 week after the procedure. RESULT In all the cases, the tumors were completely resected. Mean tumor size was 24.2 mm (12-50 mm) in diameter. The histo-logical diagnoses were leiomyoma (16/17) and gastrointestinal stromal tumor (GIST, 1/17). Subcutaneous emphysema was found in 2 patients after the procedure, but disappeared by the third day. No patients sustained perforation or developed significant hem-orrhage, and there were no other immediate severe complications after the procedure. The healing quality was satisfying in 16/17 patients evaluated by EUS 1 week after the procedure. No recurrence has been found during follow-up (mean 7 months, range 3-13 months). CONCLUSION EUS-assisted tunnel-type ESD is effective and safe in treatment of esophageal tumors arising in the muscularis pro-pria.
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Affiliation(s)
- Nan Ge
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Sheng Wang
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Guoxin Wang
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Jintao Guo
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
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Abstract
Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.
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Affiliation(s)
- Michio Asano
- Michio Asano, Endoscopic Center, Colo-proctological Institute, Matsuda Hospital, Hamamatsu, Shizuoka 432-8061, Japan
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Baron TH, Wong Kee Song LM, Zielinski MD, Emura F, Fotoohi M, Kozarek RA. A comprehensive approach to the management of acute endoscopic perforations (with videos). Gastrointest Endosc 2012; 76:838-859. [PMID: 22831858 DOI: 10.1016/j.gie.2012.04.476] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/29/2012] [Indexed: 02/06/2023]
Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 245] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
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Costamagna G, Marchese M, Familiari P, Tringali A, Inoue H, Perri V. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis 2012; 44:827-32. [PMID: 22609465 DOI: 10.1016/j.dld.2012.04.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/07/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy has been developed to provide a less invasive treatment for oesophageal achalasia compared to surgical cardiomyotomy. AIMS To report our initial experience on feasibility, safety and clinical efficacy of peroral endoscopic myotomy. METHODS Eleven patients (eight women, mean age 32, range 24-58) underwent an attempt at peroral endoscopic myotomy under general anaesthesia. After submucosal injection, a mucosal entry into the oesophageal submucosa, and a tunnel extending to the oesophagogastric junction and beyond into the stomach were created (total mean length: 15 ± 1.7 cm). Myotomy of the circular oesophageal and gastric muscle bundles was then achieved under direct vision (total mean length: 10.2 ± 2.8 cm). Haemostatic clips were used to close the mucosal entry. The Eckardt Score and manometry were used to evaluate the results. RESULTS Peroral endoscopic myotomy could be completed in 10 out of 11 patients (91%). Mean procedure time was 100.7 min (range 75-140 min). No major complication occurred. Clinical success was achieved in all patients at 1-month follow-up (Eckardt Score 7.1 vs. 1.1, p=0). Lower oesophageal sphincter pressure decreased from 45.1 to 16.9 mm Hg (p=0). CONCLUSIONS This initial experience with peroral endoscopic myotomy shows its safety and efficacy in the treatment of achalasia. Further studies are warranted to assess the long-term efficacy and to compare peroral endoscopic myotomy with other treatment modalities.
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Affiliation(s)
- Guido Costamagna
- Digestive Endoscopy Unit, Department of Surgery, Catholic University, Rome, Italy.
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Retrograde Submucosal Tunneling Technique for Management of Complete Esophageal Obstruction. Surg Laparosc Endosc Percutan Tech 2012; 22:e232-5. [DOI: 10.1097/sle.0b013e318257c9e5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Yoshida A, Hosoya T, Maselli R, Kudo SE. Training in peroral endoscopic myotomy (POEM) for esophageal achalasia. Ther Clin Risk Manag 2012; 8:329-342. [PMID: 22888256 PMCID: PMC3414088 DOI: 10.2147/tcrm.s32666] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has been developed in the context of natural orifice transluminal endoscopic surgery (NOTES) as a minimally invasive endoscopic treatment for symptomatic esophageal achalasia, which is a chronic progressive benign disease with severe morbidity and difficult management. Since September 2008, POEM has been successfully performed in more than 200 consecutive patients with symptomatic achalasia at the Digestive Disease Center of Showa University, Northern Yokohama Hospital, Yokohama, Japan, with excellent short- and long-term results and absence of serious complications. International experience of POEM within clinical studies is also promising. According to these results, POEM is considered as a safe procedure that can be applied to all achalasia patients. However, the low incidence of achalasia (0.3%-1% per 100,000 population), in combination with the potential serious complications related to the technically demanding POEM procedure, has made training difficult. There is therefore an urgent need for an animal model for training to decrease the learning curve. Further, there are other ethical and training issues to address. The pig is the most appropriate animal model for training in POEM due to its anatomy being similar to that of humans. The porcine esophagus has the advantage of easy mobilization due to absence of tight junctions to surrounding organs. A non-survival porcine model would be a simple, inexpensive, and reproducible animal model for training in POEM, without the need for concern about complications. A possible training process might first involve observation of POEM performed by specialists, then training on non-survival and survival porcine models, followed by training in humans under specialist guidance and finally, performance of POEM in humans.
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Affiliation(s)
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Manabu Onimaru
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Akira Yoshida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Toshihisa Hosoya
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Roberta Maselli
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Yoshida A, Hosoya T, Maselli R, Kudo SE. Training in peroral endoscopic myotomy (POEM) for esophageal achalasia. Ther Clin Risk Manag 2012. [PMID: 22888256 DOI: 10.2147/tcrm.s32666.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has been developed in the context of natural orifice transluminal endoscopic surgery (NOTES) as a minimally invasive endoscopic treatment for symptomatic esophageal achalasia, which is a chronic progressive benign disease with severe morbidity and difficult management. Since September 2008, POEM has been successfully performed in more than 200 consecutive patients with symptomatic achalasia at the Digestive Disease Center of Showa University, Northern Yokohama Hospital, Yokohama, Japan, with excellent short- and long-term results and absence of serious complications. International experience of POEM within clinical studies is also promising. According to these results, POEM is considered as a safe procedure that can be applied to all achalasia patients. However, the low incidence of achalasia (0.3%-1% per 100,000 population), in combination with the potential serious complications related to the technically demanding POEM procedure, has made training difficult. There is therefore an urgent need for an animal model for training to decrease the learning curve. Further, there are other ethical and training issues to address. The pig is the most appropriate animal model for training in POEM due to its anatomy being similar to that of humans. The porcine esophagus has the advantage of easy mobilization due to absence of tight junctions to surrounding organs. A non-survival porcine model would be a simple, inexpensive, and reproducible animal model for training in POEM, without the need for concern about complications. A possible training process might first involve observation of POEM performed by specialists, then training on non-survival and survival porcine models, followed by training in humans under specialist guidance and finally, performance of POEM in humans.
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36
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Kikuchi O, Mouri H, Matsueda K, Yamamoto H. Endoscopic Submucosal Dissection for Treatment of Patients Aged 75 Years and over with Esophageal Cancer. ISRN GASTROENTEROLOGY 2012; 2012:671324. [PMID: 22778977 PMCID: PMC3385636 DOI: 10.5402/2012/671324] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 04/19/2012] [Indexed: 01/31/2023]
Abstract
Background. Although many reports concerning the use of endoscopic submucosal dissection (ESD) for esophageal cancer have been published, the feasibility of ESD in elderly patients has not been reported. Therefore, we evaluated the efficacy and safety of ESD for treating early esophageal cancer in elderly patients. Methods. A total of 62 cases (52 men, 10 women; mean age ± standard deviation, 66.5 ± 10.5 years) for which the first resection (first treatment) of esophageal cancer was performed by ESD were identified from 77 consecutive esophageal epithelial cancers in 67 patients treated at our institution from January 2005 to March 2011. Patient characteristics, clinical findings, and outcomes were retrospectively assessed for patients separated into older (aged 75 years and older) and younger (aged under 75 years) groups. Results. No significant differences in specimen size, procedure time, median length of the hospital stay (8 versus 9 days; P = 0.252) or procedure-associated complications (8% versus 27%; P = 0.264) were observed between the older (n = 13) and younger (n = 49) groups. Lesions were completely resected in 12 patients and 44 patients, in the younger and older groups, respectively, and the curative resection rate was 77% and 59%, respectively. There were no deaths attributable to procedure-associated complications. Conclusions. ESD is an effective treatment for early esophageal cancer and is well tolerated by elderly patients.
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Affiliation(s)
- Osamu Kikuchi
- Department of Gastroenterology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
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Liu BR, Song JT, Qu B, Wen JF, Yin JB, Liu W. Endoscopic muscularis dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria. Surg Endosc 2012; 26:3141-8. [PMID: 22580875 DOI: 10.1007/s00464-012-2305-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 04/02/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Based on our experience with endoscopic submucosal dissection (ESD) and new endoscopic techniques for endoscopic closure of iatrogenic upper gastrointestinal (upper-GI) perforations, we developed methods to remove upper-GI subepithelial tumors (SETs) originating from the muscularis propria by endoscopic muscularis dissection (EMD). The aim of this study is to evaluate the clinical feasibility and safety of EMD. METHODS 31 patients with upper-GI SETs originating from the muscularis propria were treated by EMD. The EMD differed from ESD in (1) precutting the overlying mucosa above the lesion by using snare or longitudinal incision instead of circumferential incision, (2) dissecting the complete tumors away from submucosal and muscularis propria tissue by electrical dissection combined with blunt dissection, and (3) closing the wound with clips. Perforations occurring during dissection were closed by endoscopic methods. RESULTS 30 of 31 tumors were resected completely (96.8 %). One esophageal lesion was resected partially because of severe adhesions with surrounding tissue. Mean resected tumor size was 22.1 mm × 15.5 mm, and mean operation time was 76.8 min (range 15-330 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in 16 lesions [6 esophageal, 3 cardial, 7 gastric; 6 very low risk and 10 low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in 15 lesions (8 esophageal, 4 cardial, 3 gastric). No patient developed delayed hemorrhage. Perforation occurred in four patients (12.9 %), all of which were managed successfully by endoscopic techniques. The mean follow-up time was 17.7 months (range 7-35 months). Follow-up found no tumor recurrence in any patient. CONCLUSIONS In this early experience, EMD appears to be a feasible and minimally invasive treatment for some patients with upper-GI SETs originating from the muscularis propria. Although there is a higher risk of perforation than with ESD, this will improve with extended practice, and perforations have become manageable endoscopically.
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Affiliation(s)
- Bing-Rong Liu
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin, 150086, People's Republic of China.
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Honda K, Akiho H. Endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. World J Gastrointest Pathophysiol 2012; 3:44-50. [PMID: 22532931 PMCID: PMC3334390 DOI: 10.4291/wjgp.v3.i2.44] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/31/2012] [Accepted: 04/10/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic resection is an effective treatment for non-invasive esophageal squamous cell neoplasms (ESCNs). Endoscopic mucosal resection (EMR) has been developed for small localized ESCNs as an alternative to surgical therapy because it shows similar effectiveness and is less invasive than esophagectomy. However, EMR is limited in resection size and therefore piecemeal resection is performed for large lesions, resulting in an imprecise histological evaluation and a high frequency of local recurrence. Endoscopic submucosal dissection (ESD) has been developed in Japan as one of the standard endoscopic resection techniques for ESCNs. ESD enables esophageal lesions, regardless of their size, to be removed en bloc and thus has a lower local recurrence rate than EMR. The development of new devices and the establishment of optimal strategies for esophageal ESD have resulted in fewer complications such as perforation than expected. However, esophageal stricture after ESD may occur when the resected area is larger than three-quarters of the esophageal lumen or particularly when it encompasses the entire circumference; such a stricture requires multiple sessions of endoscopic balloon dilatation. Recently, oral prednisolone has been reported to be useful in preventing post-ESD stricture. In addition, a combination of chemoradiotherapy (CRT) and ESD might be an alternative therapy for submucosal esophageal cancer that has a risk of lymph node metastasis because esophagectomy is extremely invasive; CRT has a higher local recurrence rate than esophagectomy but is less invasive. ESD is likely to play a central role in the treatment of superficial esophageal squamous cell neoplasms in the future.
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Nicolás-Pérez D. [Endoscopic submucosal dissection: only for expert endoscopists?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:344-67. [PMID: 22341600 DOI: 10.1016/j.gastrohep.2011.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 12/29/2011] [Indexed: 12/16/2022]
Abstract
Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.
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Affiliation(s)
- David Nicolás-Pérez
- Servicio de Aparato Digestivo, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
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Endoscopic submucosal dissection for early esophageal neoplasia: a single center experience in South Taiwan. J Formos Med Assoc 2012; 111:132-9. [PMID: 22423666 DOI: 10.1016/j.jfma.2010.12.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 11/25/2010] [Accepted: 12/24/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/PURPOSE Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure to resect early gastrointestinal neoplasm. It is technically more difficult and risky when used to treat early esophageal tumors. We report our experiences related to performing ESD for early esophageal neoplasia. The efficacy, complications, and outcome were also analyzed. METHODS From December 2007 to April 2010, 22 patients with documented early esophageal neoplasm underwent ESD. All patients completed a meticulous endoscopic examination using conventional endoscopy followed by narrow-band imaging. Lugol's staining was performed to identify the margin of the suspicious lesion. Insulation-tipped diathermic knife 2 was used for ESD. RESULTS A total of 26 neoplastic lesions (including 13 tumors with high-grade dysplasia, 12 tumors with squamous cell carcinoma, and one tumor with adenocarcinoma) in 22 patients were enrolled. All patients were men. The mean age was 47.6 ± 8.6 years (range, 30-68 years). The mean size of tumors was 33.7 ± 21.7 mm (range, 8-80 mm). ESD was performed for 24 lesions in 20 patients. The mean size of resected specimens was 43.1 ± 19.2 mm (range, 15-90 mm). The mean operation time was 92.7 ± 69 minutes (range, 30-310 minutes). There were three ESD-related complications, including one with delayed bleeding, one with subcutaneous emphysema, and one with perforation. Two patients received additional operations after ESD due to deep submucosal invasion by cancer. Three lesions in two patients (12.5%) developed post-ESD esophageal stricture that needed repeated endoscopic bougination. There was no procedure-related mortality. No local recurrence was found during the follow-up period. CONCLUSION ESD is a promising local curative treatment option for early esophageal neoplasia in Taiwan. However, this procedure may result in complications that are worth noting, especially post-ESD esophageal stricture. Education regarding this procedure and more hands-on training will facilitate endoscopists to improve the outcomes of patients undergoing this procedure.
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Berr F, Ponchon T, Neureiter D, Kiesslich T, Haringsma J, Kaehler GF, Schmoll F, Messmann H, Yahagi N, Oyama T. Experimental endoscopic submucosal dissection training in a porcine model: learning experience of skilled Western endoscopists. Dig Endosc 2011; 23:281-9. [PMID: 21951087 DOI: 10.1111/j.1443-1661.2011.01129.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) demands a new level of endoscopic skill in Europe. A 2-day workshop was set up for trainees to carry out five ESD each in order to obtain the skill level required to perform ESD in the stomach or rectum. This study describes: (i) the workshop setup; (ii) the participant's performance; and (iii) the training effect on post-workshop clinical ESD performance. METHODS Eighteen very experienced European endoscopists participated in four half-day (4.5 h) training sessions, with everybody rotating daily through six separate training stations (two each with dual, hook, or hybrid knives) with expert tutors. One anesthetized piglet was used per station and session. After 1 year, the clinical ESD performance was surveyed to estimate the training effect of the workshop. RESULTS Overall, 74 ESD were performed, that is, 4.1 ESD per participant. On average ESD lasted 57 min for 6 cm(2) specimens. We detected a 22% rate of perforation (16 of 74 ESD with perforations), mostly attributable to participants with less experience in ESD. Those who started clinical ESD within 1 year after the workshop performed 144 clinical ESD (median 8 [0-20] per trainee) mostly in the stomach (40%) and large bowel (46%) with an acceptable rate of perforation (9.7%) and surgical repair (3.5%) without mortality or persistent morbidity. CONCLUSION Intense skill training for ESD is needed to reduce the risk of perforation, as demonstrated by the results of this workshop. We show that experimental ESD training, however, enables skilled European endoscopists to perform ESD in standard locations with moderate risk of perforation during the clinical learning curve.
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Affiliation(s)
- Frieder Berr
- Department of Medicine I, Paracelsus Medical University/Salzburger Landeskliniken (SALK), Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
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