Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood

En-bloc resection is desirable for accurate histopathological assessment of tissue specimens obtained using endoscopic mucosal resection (EMR). A new EMR method using sodium hyaluronate and a small-caliber-tip transparent hood has been developed. This is a peeling-off method using a needle-knife for mucosal and submucosal incisions. Long-lasting submucosal thickening resulting from an injection of sodium hyaluronate, and good visualization of the submucosal tissue with the aid of a small-caliber-tip transparent hood, make the cutting procedures easy and safe. A large superficial gastric cancer and a large villous tumor of the sigmoid colon were endoscopically resected using this method. En-bloc endoscopic resection was successful in both patients. The gastric lesion was an well-differentiated intramucosal adenocarcinoma, completely resected in a specimen measuring 97 x 50 mm. The colonic lesion was an intramucosal well-differentiated adenocarcinoma in adenoma, completely resected in a specimen measuring 70 x 55 mm in diameter. No significant complications were noted in either patient. The new method of EMR using sodium hyaluronate and the small-caliber-tip transparent hood is a promising method for endoscopic en-bloc resection of large superficial neoplastic lesions, both in the stomach and the colon.     

早期结直肠癌及癌前病变患者经内镜下黏膜切除术与黏膜剥离术治疗的疗效比较

目的比较内镜下黏膜切除术(EMR)与内镜下黏膜剥离术(ESD)在结直肠癌前病变与早期癌患者中的应用效果。方法选取2010年1月-2015年1月该院收治的116例早期结直肠癌患者与结直肠腺瘤患者为研究对象。其中,61例患者采用EMR治疗,为EMR组,55例采用ESD治疗,为ESD组。比较EMR与ESD在结直肠癌前病变与早期癌患者中的应用效果。结果 EMR组患者的手术时间明显短于ESD组患者,两组患者的病理情况、异型增生程度的差异无统计学意义(P0.05)。ESD组病变最大径≥2 cm的整块切除和病变最大径≥2 cm的组织治愈性切除的患者明显多于EMR组,差异有统计学意义(P0.05)。ESD组病变最大直径≥2 cm的患者明显多于EMR组,差异有统计学意义(P0.05)。EMR组和ESD组患者并发症总发生率分别为6.56%和23.63%,差异有统计学意义(P0.05)。EMR组和ESD组患者的复发率分别为5(8.20%)例和3(5.45%)例,差异无统计学意义(P0.05)。ESD术后出现并发症的危险因素为操作经验和病变大小(P0.05)。结论 ESD术和EMR术均能较好的整块切除病变最大径≥2 cm的早期结直肠癌与结直肠腺瘤,术后复发率较低。ESD术相对于EMR术更适合较大的病变,但术后复发率较高,且手术医师的操作经验和病变大小为ESD术后发生并发症的危险因素,应加强监测。     

Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients

BACKGROUND AND STUDY AIMS: Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium. PATIENTS AND METHODS: A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later. RESULTS: Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %). CONCLUSIONS: Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.     

Early esophageal carcinoma: endoscopic ultrasonography using the sonoprobe

Background: Almost all cases of superficial esophageal carcinoma are curable by endoscopic mucosal resection (EMR), but a precise diagnosis of the depth of tumor invasion is necessary to assess the indication for EMR. Although endoscopy has a high rate of accuracy for diagnosing the depth of tumor invasion, it depends on the experience of the examiner in interpreting surface information of the lesions. Today, endoscopic ultrasonography (EUS) is one of the most powerful techniques for obtaining objective tomographic images of a tumor. The high-frequency ultrasound probe is appropriate for EUS in cases of superficial esophageal carcinoma because of its excellent near-field resolution that provides precise ultrasound images under direct control of the endoscope. Methods: We performed EUS with the Sonoprobe System in 85 cases of superficial esophageal carcinoma before treatment and evaluated the resected specimens histopathologically. We interpreted the depth of tumor invasion based on our fundamental studies of ultrasonograms taken with a 20-MHz probe. Results: The clinical usefulness of the Sonoprobe with linear and radial scanning modes is due to its capacity to differentiate between mucosal and submucosal carcinoma by means of analyses of the muscularis mucosae. Although a clear assessment of microinvasion and lymphoid hyperplasia surrounding the tumor of interest remains speculative, the diagnostic accuracy rate for 96 lesions of superficial esophageal carcinoma reached 93% in terms of differentiating between mucosal from submucosal carcinoma. Conclusion: EUS with the Sonoprobe can play an important role in the pretreatment diagnosis of superficial esophageal carcinomas.     

消化道无蒂隆起性病变的内镜黏膜切除术和内镜黏膜下剥离术治疗分析

目的探讨内镜下粘膜切除术(EMR)和内镜粘膜下剥离术(ESD)治疗消化道无蒂隆起性病变包括早癌的疗效和安全性。方法对行EMR和ESD的43例消化道无蒂隆起性病变患者做回顾性分析。结果 43例无蒂隆起性病变食管11例,胃底4例,胃体8例,胃窦8例,贲门11例,直肠1例。EMR32例,ESD 11例。EMR病变长径、手术时间均明显低于ESD;EMR术后1例出血,无穿孔,ESD术后1例出血,2例穿孔,皆保守治疗后治愈。术后病理提示间质瘤6例,息肉23例,1例异位胰腺,7例上皮内瘤变,6例早癌。基底和切缘均未见病变累及。术后2月、6月随访,创面愈合,无病变残留和复发。结论 EMR和ESD治疗消化道无蒂隆起性病变安全有效,可以提供完整的病理诊断学资料。EMR和ESD可用于治疗消化道早癌。     

Aggressive endoscopic mucosal resection in the upper GI tract — Hook knife EMR method —

Summary

We have developed a new EMR method, the ‘Hook knife’ method, for the en-bloc resection of larger lesions. First, we placed marks around the lesion with a coagulation tip. Next, 10% glycerol diluted epinephrine solution was injected into the submucosal layer to separate the mucosa from the muscular layer proper. Then, we cut the mucosa around the lesion with a needle knife. Finally, we cut the submucosal fibers and vessels using a hook-type knife and resected the lesions. A large en-bloc resection, ≥70 mm in size, was possible with this new EMR method. Because of this, the histological examination for both the range of lateral spreading and the depth of invasion can be made more precisely. Aggressive endoscopic mucosal resection is established by this new EMR method.     

内镜黏膜下剥离术对食管胃黏膜下病变的诊疗价值

目的探讨内镜黏膜下剥离术对食管胃黏膜下病变的安全性及临床疗效。方法将2008年1月至2011年12月我院同期收治的43例经超声内镜确诊为食管胃黏膜下病变的患者随机分为内镜黏膜下剥离术(ESD)组(n=20)和内镜黏膜下切除术(EMR)组(n=23)进行手术,对比分析两组的临床资料。结果 ESD组与EMR组在性别、年龄、肿瘤部位和肿瘤大小之间差异无统计学意义(P>0.05)。ESD组术后发生出血1例(2.0%);EMR组术后发生并发症3例(6.25%),其中出血2例,穿孔1例。两组比较其差异具有统计学意义(P<0.05)。ESD组无切缘阳性者,EMR组术后切缘阳性者有2例(4.17%)(P<0.05)。ESD组患者均无复发,EMR组术后仅1例复发(2.08%)(P<0.01)。结论 ESD创伤性小;安全性高;切除病灶     

Endoscopic treatment for laterally spreading tumors in the colon

BACKGROUND AND STUDY AIMS: Laterally spreading tumors (LST) of the colon are best removed by endoscopic mucosal resection (EMR) as they extend laterally rather than vertically. Since they sometimes invade deeply into the submucosal layer, it is important to assess the depth of invasion endoscopically before treatment. In the present study, we examined the endoscopic features of a large number of LSTs in order to assess which features correlated with depth of invasion. MATERIALS AND METHODS: 257 LSTs removed at the National Cancer Center Hospital, Tokyo, between January 1988 and September 1998 were retrospectively analyzed. RESULTS: With univariate analysis, unevenness of nodules, presence of large nodules, size, histological type, and presence of depression in the tumor were significantly associated with depth of invasion. Multivariate analysis revealed that histological type and depression in the tumor were independent factors predicting massive submucosal invasion. When an LST showed: 1) even nodules without depression, or 2) uneven nodules without depression and less than 3 mm in diameter, the risk of massive submucosal invasion was 0 % (0/121) and 3.7 % (3/82), respectively. CONCLUSION: When LSTs meet the above endoscopic criteria, EMR should be the first-line treatment because of the low risk of massive submucosal invasion.     

Lésions transformées réséquées incomplètement et leur suivi. Comment les craindre macroscopiquement, quand faire le contrôle endoscopique au vu de l’histologie et que faire; seconde mucosectomie ou résection chirurgicale ? Cas de la nappe villeuse ou du polype sessile

In general, the choice of endoscopic therapy lies between mucosal resection and submucosal dissection. These forms of treatment must be restricted to neoplastic lesions not at the risk of lymph-node involvement and entail complete endoscopic resection in a single piece (monobloc) if: 1) the cancer is well or moderately well-differentiated; 2) there is no lymphatic or vascular spread; 3) there is no discontinuity of the invasive margin (“budding”); 4) the margin of healthy tissue is at least 1-mm wide; 5) there is no invasion beyond the mucosa or invasion remains confined within the superficial submucosa to a depth of less than 1 mm. The following observations or test results suggest the presence of deep invasion and, therefore, the possibility of lymph-node involvement: 1) the size and shape (surface contours) of the lesion; 2) appearance of the lesional epithelial pits; 3) endoscopic ultrasound, especially using high-frequency mini-probe; 4) separation after submucosal fluid injection. Mucosal resection is 1) indicated for sessile lesions (Is) with a base diameter greater than 10 mm, or with suspicion of submucosal carcinoma (Kudo class V); 2) indicated for class II flat lesions, which should, under no circumstances, be treated by polypectomy. If a part of the lesion is of Kudo type V, the goal of R0 (microscopically negative margins) mucosal resection is advisable only for colorectal lesions of less than 15-mm diameter; 3) contra-indicated for type III ulcerated lesions, where an alternative approach must be considered, except where there is comorbidity. Submucosal dissection or colorectal ESD is at present: 1) indicated where R0 resection is strictly necessary, i.e. when the lesions are suggestive of submucosal cancer or when the crypts have Kudo classification type V naked eye appearances (such features preclude the use of EMR); 2) contraindicated in the presence of a lesion which is not elevated after submucosal injection, for lesions with Kudo type V naked eye appearances over more than a 3 cm diameter and for ulcerated lesions. Such lesions should be managed by surgical resection, taking account of the patient’s fitness for surgery. However, the chances of relapse after EMR and, therefore, the requirement to carry out repeat endoscopy should be weighed against the risk of perforation and the technical difficulty of ESD (reflected in the time needed to perform the procedure).     

Preoperative evaluation of submucosal invasive colorectal cancer using a 15-MHz ultrasound miniprobe

BACKGROUND AND STUDY AIMS: Recently, it was reported that focal submucosal invasive colorectal cancer could be treated by polypectomy or endoscopic mucosal resection (EMR) because of the rarity of lymph-node metastasis. Our objective was to examine the accuracy and efficacy of a 15-MHz ultrasound miniprobe in the preoperative evaluation of the degree of submucosal invasion in colorectal cancer. PATIENTS AND METHODS: A total of 35 patients with submucosal invasive colorectal cancer who underwent ultrasonography with a miniprobe were studied prospectively. The results of this imaging were compared with the histologic findings in resected specimens. RESULTS: Although the accuracy of the miniprobe in categorizing submucosal invasion into three subclasses (SM1, invasion limited to the upper third; SM2, limited to the middle third; SM3, limited to the lower third) was low (37.1%; 13/35), the accuracy in differentiation between < or = SMI (M and SMI) and > or = SM2 (SM2, SM3, MP, and S) was 85.7 % (30/35). CONCLUSIONS: The miniprobe can be useful for therapeutic decision-making in submucosal invasive colorectal cancer.     

Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions

AIM: To compare the outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) of colorectal lesions. METHODS: An electronic systematic literature search of four computerized databases was performed in July 2014 identifying studies reporting the outcomes of colorectal ESD and EMR. The primary outcome measures were en-bloc resection rate, endoscopic clearance rate and lesion recurrence rate of the patients followed up. The secondary outcome was the complication rate (including bleeding, perforation and surgery post EMR or ESD rate). Statistical pooling and random effects modelling of the studies calculating risk difference, heterogeneity and assessment of bias and quality were performed. RESULTS: Six observational studies reporting the outcomes of 1324 procedures were included. The en-bloc resection rate was 50% higher in the ESD group than in the EMR group (95%CI: 0.17-0.83, P < 0.0001, I² = 99.7%). Endoscopic clearance rates were also significantly higher in the ESD group (95%CI: -0.06-0.02, P < 0.0001, I² = 92.5%). The perforation rate was 7% higher in the ESD group than the EMR group (95%CI: 0.05-0.09, P > 0.05, I² = 41.1%) and the rate of recurrence was 50% higher in the EMR group than in the ESD group (95%CI: 0.20-0.79, P < 0.001, I² = 99.5%). Heterogeneity remained consistent when subgroup analysis of high quality studies was performed (with the exception of piecemeal resection rate), and overall effect sizes remained unchanged for all outcomes. CONCLUSION: ESD demonstrates higher en-bloc resection rates and lower recurrence rates compared to colorectal EMR. Differences in outcomes may benefit from increased assessment through well-designed comparative studies.     

Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus

BACK AND STUDY AIMS: Endoscopic mucosal resection (EMR) is used to treat premalignant and malignant digestive tract lesions. This report presents the efficacy and safety of EMR for squamous superficial neoplastic esophageal lesions. PATIENTS AND METHODS: A retrospective cohort study presented data from 51 patients with 54 lesions over an 8-year period, between November 1997 and September 2005. Dysplasas or mucosal (m) T1 carcinomas were treated with repeated EMR until there was a complete local remission. Patients with submucosal (sm) T1 carcinomas were treated with repeated EMR until there was a complete local remission. Patients with submucosal (sm) T1 carcinomas or more advanced stage were offered surgery or chemoradiotherapy. RESULTS: There was no mortality, perforation, or major hemorrhage, and there were three easily dilated stenoses. Of the patients, 16 had lesions graded as T1sm or more advanced and one patient was found to have normal tissue post EMR. Complete local remission was achieved in 31 of the 34 patients with dysplasia or T1 m cancers (91%). There was no distant relapse and there was local disease recurrence in eight of the 31 patients (26%). The 5-year survival rate was 95%. CONCLUSIONS: EMR for squamous superficial neoplastic lesions of the esophagus is safe and provides satisfactory survival results.     

Endoscopic submucosal dissection for residual/local recurrence of early gastric cancer after endoscopic mucosal resection

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) is a widely accepted treatment for early gastric cancer; however, incomplete resection with residual local disease and recurrences continues to be a difficult problem. The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for residual/local recurrent early gastric cancer lesions after EMR. PATIENTS AND METHODS: The en bloc resection rate, histologically complete resection rate, complications, and local recurrence were assessed in 15 patients who underwent ESD for residual/local recurrent early gastric cancer lesions after EMR. RESULTS: The nonlifting sign after injection of a glycerin solution was positive due to scar formation in all cases. En bloc resection was attempted in all cases, with a complete resection rate of 93.3 % (14 of 15). The lesion was completely resected with histologically adequate margins in the 14 patients who received complete en bloc resection. The average operation time was 85.4 +/- 52.9 min, and the mean follow-up period for all patients was 18.1 +/- 7.4 months. Major bleeding during the procedure in one case was the only complication (one of 15, 6.7 %). None of the patients experienced recurrence of early gastric cancer after ESD. CONCLUSIONS: ESD appears to be a safe and effective treatment for residual/local recurrent early gastric cancer lesions after EMR, and it is useful for histological confirmation of successful treatment.     

Magnifying endoscopy, stereoscopic microscopy, and the microvascular architecture of superficial esophageal carcinoma

BACKGROUND AND STUDY AIMS: In this study we clarify the microvascular architecture of superficial esophageal carcinoma as observed by ultra-high magnification endoscopy and stereoscopic microscopy with Microfil injection. PATIENTS AND METHODS: We observed two surgically resected specimens of superficial esophageal cancer under stereoscopic microscopy with Microfil injection. In addition, in the histological investigation, we measured the caliber of the vessels at the surface of the tumor. We carried out ultra-high magnification before treatment in 82 patients with superficial esophageal neoplasms. We classified the depth of tumor penetration of superficial esophageal carcinoma into four categories: m1 to m3 (mucosal cancer) and sm (submucosal cancer). RESULTS: By observing the normal esophageal mucosa under a stereoscopic microscope and an ultra-high magnification endoscope, we were able to visualize the intrapapillary capillary loops (IPCL). In cancer lesions, we observed characteristic changes in the superficial microvascular architecture according to the depth of tumor invasion. In m1 invasion, there was dilatation of the IPCL; in m2 invasion, there was dilatation and elongation of the IPCL; in m3, there was a mixed appearance of the IPCL and tumor vessels; and in sm invasion, complete replacement by tumor vessels. On the basis of the above criteria, ultra-high magnification endoscopic observation before treatment showed a rate of agreement between histological depth of invasion and magnified appearance of 60/72 cases (83.3 %) for which satisfactory pictures were obtained. The histological investigation showed the caliber of the IPCL of the m1 cancer lesions (12.9 +/- 3.9 microm) to be significantly greater than that of the normal esophageal mucosa (6.9 +/- 1.5 microm) (P < 0.0001). CONCLUSIONS: Observation of the microvascular architecture of superficial esophageal carcinoma is useful in the diagnosis of the depth of invasion.     

Indications, Knives, and Electric Current: What's the Best?

Endoscopic submucosal dissection (ESD) was developed to overcome the limitations of conventional endoscopic mucosal resection (EMR), and ESD has been also applied for large colorectal neoplasms. Since colorectal ESD is still associated with higher perforation rate, a longer procedure time, and increased technical difficulty, the indications should be strictly considered. Generally, colorectal tumors without deep submucosal invasion or minimal possibility of lymph node metastasis, for which en bloc resection using conventional EMR is difficult, are good candidates for colorectal ESD. The ideal knife for colorectal ESD should avoid making perforations but can make a clean cut of optimal depth at one time. The ideal current for ESD differs depending on the procedure used, the surgical devices used, the tissue to be dissected, and the operator's preference. Application of the optimal indications and improvements in the technical skill and surgical devices are required for easier and safer colorectal ESD.     

Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastrointestinal cancers has been shown to be effective in treating mucosal malignancies, but en bloc resection (where the entire tumor is removed in one piece) is often not achieved using conventional cap EMR. Other techniques, developed in Japan, include the application of different types of knife such as the insulated-tip instrument. We report our preliminary experience of the use of this knife, in conjunction with other techniques, in attempting en bloc resection of early mucosal cancers and adenomas and in the removal of submucosal tumors (SMTs) of the upper gastrointestinal tract. PATIENTS AND METHODS: A total of 37 patients (26 men, 11 women, age range 53 - 86) were included in the study; 23 patients had 24 mucosal lesions amenable to EMR, and 14 patients had SMTs shown on endosonography to spare the muscularis propria. Lesions were located in the esophagus (n = 13), the stomach (n = 24), and the duodenum (n = 1); 40 % of the mucosal lesions were 20 mm or larger (mean size 18mm), whereas the mean size of the submucosal lesions was 23 mm. After submucosal saline injection, circumcision and dissection of the mucosal lesions was attempted with the aim of achieving en bloc resection. For SMTs, cap mucosectomy of the overlying mucosa was done first, and the tumors were then freed using saline injection, and finally resected using snare polypectomy. RESULTS: The strict aim of the study, i. e. complete tumor removal in a single piece, was achieved in only 25 % of the mucosal lesions (some failures were due to unrecognized submucosal infiltration) and 36 % of the SMTs. When a more liberal definition of success was assumed, this rate increased to 65 % for mucosal lesions (piecemeal, no tumor found at surgery or follow-up endoscopy with biopsy) and 79 % for SMTs (piecemeal). No severe complications necessitating surgery or leading to major morbidity occurred. However, clinically significant complications were found in six patients (minor perforation managed conservatively (n = 1), severe pain without perforation (n = 1), bleeding requiring reintervention (n = 3), and aspiration (n = 1)). CONCLUSIONS: Although we are convinced that methods of achieving en bloc resection of mucosal cancers and SMTs must be pursued, the insulated-tip knife in conjunction with conventional endoscopes still has limitations. Innovative endoscope design (double-channel scopes) as well as the development of new accessories will help to overcome the current limitations and further promote endoscopic tumor resection.     

结直肠上皮内瘤变及早期结直肠癌内镜治疗手术前后病理结果对比分析

目的探讨结直肠上皮内瘤变及早期结直肠癌内镜切除术前后病理的差异,为提高结肠镜诊断早期结直肠癌的敏感度和特异度提供参考。方法根据纳入与排除标准,确定活检及手术均由我院完成的129例病例作为研究样本。回顾性分析确诊为结直肠高级别上皮内瘤变或早期结直肠癌患者内镜下黏膜切除术(endoscopic mucosal resection,EMR)/内镜黏膜下剥离术(endoscopic submueosal dissection,ESD)标本资料及其术前病理活检资料129例,比较术前、术后病理结果差异,并分析内镜治疗手术前后病理差异的相关危险因素。比较不同部位(升结肠、横结肠、降结肠、乙状结肠、直肠)及病灶形态(带蒂、广基、侧向发育型)、病灶最长直径、性别、年龄患者的病理活检和EMR/ESD标本病理结果准确性的差异。结果结肠镜术前活检病理与内镜EMR/ESD治疗术后病理诊断符合率为17.1%(22/129),内镜治疗术后病理诊断升级者为103例(79.8%),病理诊断降级者为4例(3.1%)。各个部位轻判率分别为82.4%、80.0%、85.7%、80.9%、76.7%,差异无统计学意义(P>0.05)。单因素Logistic回归分析结果表明:带蒂息肉患者术前活检轻判的现象更明显,差异有统计学意义(P<0.05),而对于病灶位置、最长直径、性别、年龄差异的患者术前活检轻判率差异无统计学意义(P>0.05)。结论术前活检病理诊断与EMR/ESD术后病理诊断的符合率较低,但其为内镜随访和手术治疗方式的选择提供一定依据;带蒂息肉患者更容易发生术前活检轻判,所以对带蒂息肉患者活检诊断上皮内瘤变,可根据情况,必要时结合窄带成像放大内镜技术,来选择EMR/ESD手术,并结合术后标本病理诊断情况来决定是否需要后续治疗及内镜随访时间。     

Treatment of esophagogastric tumors

Esophageal and gastric tumors are often considered as a single group: they share similar symptoms - upper GI endoscopy with a flexible video-endoscope is the gold standard procedure of detection - similar techniques of endotherapy for cure or palliation are offered for both types of tumors. When the endoscopic procedure is performed for a superficial cancer or its precursors, with a curative intent, endoscopic mucosal resection (EMR) is generally preferred to mucosal ablation with a thermal (Nd:YAG) or non-thermal (photodynamic therapy) procedure. In addition to esophageal squamous cell cancer and gastric cancer, new indications of EMR arise in the Barrett esophagus. Guidelines for safe indications concern diameter, polypoid or non polypoid morphology with the subtypes elevated, flat and depressed, and depth of invasion. A superficial invasion in the sub-mucosa is a relative contra-indication in the esophagus, but not in the stomach. The technique of EMR is now codified with an injection into the submucosa for lifting the lesion and either suction with a cap, grasping with a forceps if a 2 channel instrument is used, or tissue incision with a needle knife. En bloc, gives better results than piecemeal resection. The most frequent complication is bleeding. When legitimate indications are respected, the results of EMR are equivalent to those of surgical resection and have reached the consensus level. The major indication in palliation is the relief of dysphagia from malignant esophageal obstruction. Increased indications are proposed for malignant pyloric obstruction. Multiple models of metal expandable and coated stents with appropriate balance between rigidity and flexibility (nitinol alloy) and enough expansive radial force are now offered. After stenting the survival period is short and there is a toll of complications.     

What are the appropriate indications for endoscopic mucosal resection for early gastric cancer? Analysis of 256 endoscopically resected lesions

BACKGROUND AND STUDY AIMS: Although endoscopic mucosal resection (EMR) for early gastric cancer (EGC) without ulceration or scarring has been very popular in Japan and thought to be beneficial, curability by EMR is still lower than that for surgical resection. We investigated patients whose EGCs were resected endoscopically in order to identify the factors affecting curability by EMR. PATIENTS AND METHODS: We investigated retrospectively 256 EGC lesions (251 patients) which were subjected to EMR between 1989 and 1998 with respect to patient profile, macroscopic type, location, maximum diameter of tumors, resection method and histological typing. The prognoses of the patients were also investigated as far as possible. RESULTS: The curative total resection rate for EMR of EGC was 74.2 %. Concerning the factors affecting curability, the size of the lesion (over 15 mm), the method of resection (divisional resection), and histological typing (poorly differentiated) had a statistically significant effect on the complete resection rate. Multivariate analysis of the factors confirmed these results. Submucosal invasion was suspected in 16 patients after EMR, but submucosal cancer was found in only one patient after further surgery. Where there was recurrence, the longest recurrence-free period after EMR of EGC was 48 months, whereas the mean recurrence-free period was 195.4 days. CONCLUSIONS: The appropriate indication for EMR for EGC is thought to be an intramucosal differentiated-type adenocarcinoma without ulceration or scarring, and no more than 15 mm in size regardless of macroscopic type. Periodic follow-up for at least 5 years is necessary.     

Endoscopic submucosal dissection (ESD) of early neoplastic gastric lesions using a new double-channel endoscope (the "R-scope")

BACKGROUND AND STUDY AIM: Endoscopic submucosal dissection (ESD) allows en bloc resection of lesions > 2 cm in diameter. However the procedure is difficult because of limited visualization of the cutting area. The aim of this study was to evaluate a new endoscope (the "R-scope") for ESD; this provides a second flexible section for improved positioning capability and two instrumentation channels for vertical lifting of the targeted mucosal area and horizontal cutting of the submucosa. METHODS: The R-scope was tested first for ESD of 17 predetermined gastric areas in eight anesthetized pigs. Clinical experience was then prospectively obtained in 10 patients with early gastric neoplasia. In both instances, dye-stained saline solution was used for repeated submucosal injection. Various types of knives were available for circumferential cutting of the mucosa to isolate the targeted lesion. The specimen was then lifted and the submucosal layer was dissected with the appropriate type of knife to achieve en bloc resection. RESULTS: ESD succeeded in 14/17 animal cases (82 %), remained incomplete in two cases and failed in one because of an intractable perforation; a further two small perforations were clipped. In 10 patients (with nine early carcinomas and one adenoma, with a median diameter of 22 mm), lesions were completely resected in six cases. Surgery was necessary in two patients due to early and delayed perforation. Three other patients with small amounts of free air were conservatively managed but elective surgery was performed in two of these patients because of incomplete resection or deep submucosal tumor infiltration. CONCLUSIONS: The R-scope facilitated ESD of large gastric areas in live animal testing and in a small series of patients However the procedure is technically demanding and time-consuming. It was also associated with a high risk of perforation; this may be related to an insufficient volume of solution being injected submucosally, excessively forceful lifting of the specimen, or the short learning period.