Minimally Invasive Surgery for Gastric Cancer: The Future Standard of Care

Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.     

Endoscopic submucosal dissection training with ex vivo human gastric remnants

Background

Endoscopic submucosal dissection (ESD) offers en bloc resection of early cancer or precancerous lesions, potentially saving patients from major organ resection, such as gastrectomy, colectomy, and esophagectomy. Japan now leads the world in ESD due to its high rate of gastric cancer. Western countries, with their lower gastric cancer rates, do not get as much experience with the technique. Training in ESD utilizing both in vivo and ex vivo porcine stomach has been shown to decrease rates of perforation and operative time. Both models can be prohibitively expensive or not generally available to the majority of endoscopists on a regular basis. This study describes the framework for using human gastric remnants from sleeve gastrectomy patients for ESD training.

Methods

Patients undergoing sleeve gastrectomy for morbid obesity were consented for use of their gastric specimen before surgery. The specimen was weighed and measured by the pathologist and then used for ESD training. The specimen was mounted to a 15-mm laparoscopic port and secured using a pursestring suture. ESD was then performed through this port.

Results

We were able to successfully use this model to resect multiple marked out lesions in an en bloc fashion. Training using this model has improved our dissection times from approximately 2 h to 30 min for a 2-cm simulated lesion.

Conclusions

ESD requires the endoscopist to perform a surgical dissection. Until now, development of these skills required intensive training on porcine models that are not widely available. We were able to create a method using the excised portion from sleeve gastrectomy patients, providing a more accessible and cost-effective model for ESD training and potentially other endoscopic therapeutic modalities.     

Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years

Background

Endoscopic submucosal dissection (ESD) is an alternative to surgical resection for treating early gastric cancer (EGC). However, there have been limited reports on the long-term outcome of ESD compared to that of surgical resection. The aim of this study was to evaluate the immediate and long-term clinical and oncologic outcomes of ESD compared to surgical resection.

Method

We retrospectively reviewed data of patients in five centers who were treated with ESD or surgical resection for EGC within expanded criteria for ESD from 2006 to 2008.

Result

ESD group had significantly shorter procedure times, shorter fasting period, and shorter hospital stay than the surgical resection group. Immediate complications in the surgical resection group were more common compared to those in the ESD group. Five-year cancer recurrence rate of the ESD group was 12.3 % and significantly higher than 2.1 % of the surgical resection group (P = 0.001). Five-year disease-free survival rate of the surgical resection group was 97 %, which was significantly higher than 85 % of the ESD group (P = 0.001). Metachronous lesions were equally found every year during the follow-up period in the ESD group. Five-year overall survival rates were 100 % for both groups.

Conclusion

ESD might be an acceptable and effective treatment for EGC considering overall survival rates with fewer early complication rates and shorter duration of hospital stay compared to surgical resection. However, intensive and persistent endoscopic surveillance should be performed after ESD for early detection of metachronous lesions.

     

内镜治疗胃胃肠间质瘤的可行性

近年来,随着消化内镜技术的发展,以内镜黏膜下剥离术（ESD）及其衍生技术包括内镜黏膜下挖除术（ESE）、内镜下全层切除技术（EFR）、内镜经隧道肿瘤切除术（STER）和腹腔镜内镜联合手术（LECS）等的内镜切除技术可治疗绝大多数的胃GIST。本文就内镜治疗胃GIST的指征、方法和疗效评价进行评述。     

A scoring system for patients with a tumor-positive lateral resection margin after endoscopic resection of early gastric cancer

Background

The aim of this study was to identify the risk factors for residual/recurrent tumors in patients with a tumor-positive lateral resection margin (LRM+) after endoscopic resection of early gastric cancer (EGC) and to establish the criteria for performing additional treatment.

Methods

A retrospective analysis was performed on consecutive patients who underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of EGC. Clinicopathological characteristics and risk factors for residual/recurrent tumor in LRM+ patients were analyzed.

Results

Eighty-two patients (84 lesions) with LRM+ after EMR (n = 45) or ESD (n = 39) were enrolled. Forty patients underwent additional gastrectomy or ESD, and 44 were closely observed. The residual/recurrent tumor rate was 34.5 % (29 of 84 lesions). Univariate analysis found that the residual/recurrent tumor was associated with the endoscopic resection type (EMR), undifferentiated histology, number of involved directions, rate of lateral resection margin involvement and the total length (mm) of the lateral resection margin involved by the tumor. In multivariate logistic regression analysis, undifferentiated histology and rate (%) were independent risk factors (odds ratio [OR] 5.28, 95 % confidence interval [CI] 1.13–24.72, p = 0.035 and OR 1.08, 95 % CI 1.03–1.14, p = 0.004, respectively). Clinicopathological factors that were identified from the univariate and multivariate analyses were scored in order to predict residual/recurrent tumors.

Conclusion

We suggest a scoring system for additional treatment in patients with LRM+ after endoscopic resection of EGC based on the development of residual/recurrent tumors. This scoring system enables a more detailed selection of cases and may be useful in determining further treatment.

     

Endoscopic submucosal dissection used for treating early neoplasia of the foregut using a combination of knives

Background Endoscopic submucosal dissection (ESD) has emerged as a novel technique for achieving en bloc resection for early esophageal or gastric carcinoma limited to the mucosa. The authors report their experience with a combination of various devices to treat early neoplasia of the foregut using the ESD technique. Methods In this prospective case series, ESD was performed for early esophageal or gastric carcinoma limited to the mucosa. These lesions were staged by endoscopic ultrasonography before resection. Magnifying endoscopy and chromoendoscopy were used to locate the tumor and define the margin. The resection was accomplished with submucosal dissection using the insulated tip knife, the hook knife, and the triangular tip knife. The resected specimen was examined systematically for the lateral and deep margins. Results From January 2004 to March 2006, ESD was performed to manage 30 cases of early gastric or esophageal carcinoma. For 29 of these patients, R0 resection was successfully achieved. The mean operating time was 84.6 min. One patient experienced reactionary hemorrhage 12 h after resection, which was controlled endoscopically. There was no perforation. Most of the circumferential mucosal incisions were performed using the insulated tip knife (76.6%), whereas submucosal dissection was accomplished with a combination of various knives. One of the specimens showed involvement of the lateral margin, whereas another patient had two areas of new early gastric cancer 6 months after the initial procedure. These patients received salvage laparoscopically assisted gastrectomy. Conclusions Endoscopic submucosal dissection to manage early neoplasia of the foregut can be achieved safely and effectively with a combination of knives. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

双镜联合治疗早期胃癌的临床体会

目的:探讨胃镜、腹腔镜双镜联合治疗早期胃癌的安全性与可行性。方法:回顾分析近6年双镜联合治疗78例早期胃癌患者的临床资料。胃体、远端胃肿瘤非溃疡患者行内镜黏膜下剥离术,近端胃及胃体、远端胃肿瘤合并溃疡患者行双镜联合下腹腔镜胃楔形切除术。标本送快速病理检查。结果:为早期胃癌浸润至黏膜下层及肌层、伴有脉管癌栓、肿瘤直径>20 mm、低分化腺癌(包括印戒细胞癌)的30例患者行腹腔镜胃癌D2根治术,5例近贲门或幽门部位肿瘤患者行单纯胃大部切除术,43例患者仅行内镜黏膜下剥离术或单纯胃楔形切除术。根治患者术后淋巴结转移占全部病例的11.5%,术后均无并发症发生,患者痊愈出院。结论:双镜联合治疗早期胃癌安全、患者创伤小、康复快、疗效确切,更加体现了微创优势,避免了部分患者不必要的根治切除甚至全胃切除的痛苦,值得临床推广。     

Laparoscopic lymph node dissection after endoscopic submucosal dissection: a novel and minimally invasive approach to treating early-stage gastric cancer

BACKGROUND AND OBJECTIVE: Endoscopic submucosal dissection (ESD), a newly developed endoscopic mucosal resection (EMR) technique, can completely cure a differentiated mucosal gastric cancer smaller than 2 cm. For early-stage gastric cancers (EGCs) deviating from the above-mentioned criterion, gastrectomy with lymph node dissection is performed for potential risk of lymph node metastasis (LNM). However, many of surgical EGC cases actually do not have LNM, indicating this surgery may not be necessary for many cases of EGC. To avoid this unnecessary surgery, we have introduced laparoscopic lymph node dissection (LLND) after ESD. Standard gastrectomy with extended lymph node dissection is indicated for patients if LLND reveals LNM. We present our novel approach and the preliminary results of EGC patients having potential risk of LNM. METHODS: Five patients with EGC deviating from the EMR criterion underwent the combination of ESD and LLND. ESD was performed using a newly developed insulation-tipped diathermic knife. Lymph nodes, which were determined on the basis of the location of the primary tumor and lymphatic drainage of the stomach, were removed laparoscopically. The lymphatic drainage was visualized by submucosally injecting indocyanine green (ICG) around the post-ESD ulcerative scars during intraoperative gastroscopy. RESULTS: The ESD enabled en bloc resection without any complications. The resected margins of all the lesions were free of cancer cells vertically and horizontally. LLND was successfully performed without any complications. The mean number of the dissected lymph nodes was 15 (range 6 to 22). In 4 of the 5 patients, the dissected lymph nodes were free of cancer cells, and therefore, the combination of ESD and LLND was considered a definitive treatment. The remaining patient was found to have LNM but chose not to undergo any surgery. During follow-ups, the patients' previous quality of life was restored without any tumor recurrence. CONCLUSIONS: The combination of ESD and LLND enables the complete resection of the primary tumor and the histologic determination of lymph node status. This combination treatment is a potential, minimally invasive method, and may obviate unnecessary gastrectomy without compromising curability for EGC patients having the potential risk of LNM.     

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis

Background  

Endoscopic submucosal dissection (ESD) allows en bloc resection of the entire lesion, permitting a higher curative resection rate and increased quality of life by minimizing the resection size compared with that of endoscopic mucosal resection (EMR). Although ESD has been implemented at most university hospitals in Korea, potential complications of ESD such as bleeding and perforation raise doubts in the therapeutic decision on use of the ESD procedure for early gastric cancer patients and in reimbursement decision making. This systematic review aimed to address both the effectiveness and safety outcomes of ESD versus EMR for early gastric cancer.     

Effect of non-curative endoscopic submucosal dissection on short-term outcomes of subsequent surgery for early gastric cancer

BackgroundWith growing incidence of early gastric cancer (EGC), endoscopic submucosal dissection (ESD) is widely performed as a standard treatment for mucosal cancer. Due to the increasing application of ESD, the number of non-curative resection after ESD is also growing, leading to escalating number of patients who require additional gastrectomy with lymph node dissection after non-curative ESD. However, effects of ESD prior to surgery on technical difficulties during operation for EGC remain unclear. Therefore, this study aimed to determine the effect of non-curative ESD on short-term surgical outcomes in patients who underwent additional surgical treatment using propensity score matching method.MethodsTo evaluate the effect of ESD on short-term surgical outcomes in patients who underwent additional surgical treatment after a non-curative ESD procedure, patients were divided into two groups: (1) those who underwent additional gastrectomy after non-curative resection of ESD [ESD + Surgery (ES) Group], and (2) those who underwent gastrectomy as the initial treatment [Surgery Only (SO) Group]. To minimize differences in baseline demographic features that could potentially be associated with short-term outcomes, propensity-scored matching analysis was performed.ResultsAfter propensity-scored matching (1:1 matching), 140 patients altogether were selected and analyzed in this study. Complications were experienced by 18 (25.7%) patients in the ES group and 13 (18.6%) patients in the SO group, showing no significant (p < 0.416) difference between the two groups.ConclusionsAdditional surgery after non-curative ESD can be safely applied, even within one month after ESD in terms of short-term complications.     

Endoscopic submucosal dissection (ESD) compared with gastrectomy for treatment of early gastric neoplasia: a retrospective cohort study

Introduction

This study aims to compare perioperative outcomes and oncological clearance of endoscopic submucosal dissection (ESD) versus gastrectomy for treatment of early gastric cancer (EGC).

Methods

This is a retrospective cohort study including all cases of EGC or severe dysplasia treated at a university-affiliated hospital from 1993 to 2010. Preoperative endoscopic ultrasound and image-enhanced endoscopy were employed to determine depth of invasion. Clinical outcomes including baseline demographics, pathology, postoperative complication, and hospital stay, as well as 3-year survival were compared.

Results

From 1993 to 2010, 114 patients with severe dysplasia or EGC were treated: 40 of them received gastrectomy, while 74 received ESD. There was no difference in age, gender, comorbidity or American Society of Anesthesiologists grade between the two groups. Of patients in the gastrectomy group, 92.5?% presented with symptoms as compared with 27.0?% of those treated by ESD (p?<?0.001). More patients in the ESD group had atrophic gastritis (31.1 vs 10?%; p?=?0.009) and intestinal metaplasia (68.9 vs 55.0?%; p?=?0.04). Patients treated by gastrectomy sustained longer operative time [265 (150?C360) min] when compared with ESD [89.6 (45?C360) min; p?<?0.001]. They also had longer median hospital stay [9.9 (6?C26) days vs 3.0 (2?C10) days; p?<?0.001]. There was no perioperative mortality, but the overall complication rate was significantly higher in the gastrectomy group. The 3-year survival rate was 94.6?% for ESD and 89.7?% for gastrectomy group (log-rank test, p?=?0.44).

Conclusions

ESD achieved similar oncological outcomes when compared with radical gastrectomy for treatment of EGC. Patients receiving ESD had better perioperative outcomes in terms of operative time, complication rate, and hospital stay.     

Laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection for early gastric cancer

Background There has been a trend toward minimally invasive treatment of early gastric cancer. We report the preliminary results of laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection. Methods Six patients underwent laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection between February 2002 and October 2005 at Mie University Hospital. These patients first underwent laparoscopic sentinel lymph node biopsy and then laparoscopy-assisted distal gastrectomy with lymphadenectomy. Results No patient underwent conversion to open surgery during the operation. None of the patients had any postoperative complications. The mean length of postoperative hospital stay was 11.3 days. Sentinel lymph nodes were identified laparoscopically in five patients. There were 20 sentinel and 85 nonsentinel lymph nodes in the six patients. Postoperatively, tissue sections showed that none of the lymph nodes were metastasized. Immunohistochemistry with D2-40 antibody showed that there were normal lymphatics in the submucosal layer with mucosal defects at the endoscopic mucosal resection site. No patients had any tumor recurrence during followup. Conclusions Laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection was a safe and curative procedure. Endoscopic mucosal resection before sentinel lymph node biopsy was acceptable for early gastric cancer.     

Kolorektale Adenome: Pro konventionelle/laparoskopische Resektion

The knowledge that due to the adenoma-cancer sequence polyps will develop sooner or later into invasive cancer demands the complete removal of colorectal polyps. The majority of polyps can be endoscopically removed. The indications for surgical removal of polyps are a previous incomplete endoscopic resection, location not amenable to endoscopic removal and lesions which are macroscopically highly suspicious for malignancy and cannot be detached by submucosal saline injection. If a surgical approach is indicated minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas suspicious for malignancy in the lower two thirds of the rectum should not be treated by time-consuming endoscopic submucosal dissection (ESD) and can be quickly and safely removed transanally, conventionally or by transanal endoscopic microsurgery (TEM) by a full thickness én bloc resection. This allows the pathologist to determine the depth of invasion and the completeness of resection in terms of the circumferential margin and a definitive radical surgical approach is only necessary in high risk situations.     

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内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)作为一种治疗早期胃癌新技术,同样适用于治疗食管胃结合部(esophagogastric junction,EGJ)的浅表癌。ESD治疗食管胃结合部腺癌(adenocarcinoma of the esophagogastric junction,AEG)及EGJ处癌前病变,与外科剖腹手术及内镜黏膜切除术(endoscopic mucosal resection,EMR)等内镜治疗方法相比,具有明显优势。但ESD治疗EGJ处病变,手术难度较高,手术时间更长,手术并发症发生率更高,对操作者的技术要求较高。     

Complete defect closure of gastric submucosal tumors with purse-string sutures

Background

Gastric submucosal tumors (SMTs) originating from the muscularis propria layer are treated endoscopically. Successful closure of the wall defect is a critical step. This study evaluated the safety and feasibility of the endoscopic purse-string suture (EPSS) method using an endoloop and several metallic clips after endoscopic full-thickness resection (EFTR) or perforation due to endoscopic submucosal dissection (ESD).

Methods

From December 2009 to April 2013, 30 patients with SMTs originating from the muscularis propria layer who received EFTR or ESD were retrospectively analyzed. After successful tumor resection, an endoloop was anchored onto the circumferential margin of the gastric defect with several metallic clips and tightened gently. Patient characteristics, tumor size, en bloc resection, and postoperative complications were evaluated.

Results

For all 30 patients, EPSS was successfully performed after EFTR or perforation due to ESD. The mean diameter of the resected specimen was 1.9 cm. No severe complications occurred during or after the procedure. The lesions were healed 1 month after the procedure, as confirmed endoscopically.

Conclusion

The EPSS method using an endoloop and clips is an effective and safe technique for closing the gastric defect after EFTR or perforation due to ESD.     

Management of the colorectal polyp referred for resection: A case-matched comparison of advanced endoscopic surgery and laparoscopic colectomy

Background

Colonoscopy is the gold standard for colorectal screening and surveillance. Advanced endoscopic polypectomy techniques such as endoscopic submucosal dissection (ESD) have been introduced to remove large colorectal polyps. Our aim was to compare the outcomes of patients who underwent ESD with those of who underwent laparoscopic colectomy for benign colorectal polyps.

Efficacy of hybrid endoscopic submucosal dissection with SOUTEN in gastric lesions: An ex vivo porcine model basic study

BACKGROUNDHybrid endoscopic submucosal dissection (ESD) that comprises mucosal incision and partial submucosal dissection followed by snaring in a planned manner, has been developed for endoscopic resection of gastrointestinal neoplasms to overcome the technical barrier of ESD. Although the superiority of hybrid ESD with SOUTEN, a single multifunctional device, over conventional ESD has been indicated, the actual effect of snaring itself remains unclear since SOUTEN could be applied to hybrid ESD group, but not to the conventional ESD group, due to ethical issue in clinical practice. AIMTo determine whether and how hybrid ESD was superior to conventional ESD in the endoscopic treatment of gastric lesions in an ex vivo porcine model basic study.METHODSSixteen endoscopists participated in this basic study in August 2020 at Kyushu University, performing 32 procedures each for hybrid ESD and conventional ESD. Mock lesions (10-15 mm, diameter) were created in the porcine stomach. The primary outcome was total procedure time and secondary outcomes were en bloc or complete resection, perforation, procedure time/speed for both, mucosal incision, and submucosal dissection. Factors associated with difficulty in ESD including longer procedure time, incomplete resection, and perforation, were also investigated. Categorical and continuous data were analyzed using the chi-square test or Fisher’s exact test and the Mann-Whitney U test, respectively.RESULTSThe median total procedure time of hybrid ESD was significantly shorter than that of conventional ESD (median: 8.3 min vs 16.2 min, P < 0.001). Time, speed, and the amount of hyaluronic acid during submucosal dissection were more favorable in hybrid ESD than conventional ESD (time, 5.2 min vs 10.4 min, P < 0.001; speed, 43.7 mm²/min vs 23.8 mm²/min, P < 0.00; injection volume, 1.5 mL vs 3.0 mL, P < 0.001), although no significant differences in those factors were observed between both groups during mucosal incision. There was also no significant difference between both groups in the en bloc/complete resection rate and perforation rate (complete resection, 93.8% vs 87.5%, P = 0.67; perforation, 0% vs 3.1%, P = 1). Selection of conventional ESD as the treatment method was significantly associated with difficulties during ESD (odds ratio = 10.2; highest among factors). CONCLUSIONHybrid ESD with SOUTEN improves the treatment outcomes of gastric lesions. It also has the potential to reduce medical costs since SOUTEN is a single multifunctional device that is inexpensive.     

Role of computed tomography scan for the primary surveillance of mucosal gastric cancer after complete resection by endoscopic submucosal dissection

Background

Abdominal computed tomography (CT) scan is periodically performed in almost all patients with early gastric cancer after undergoing endoscopic submucosal dissection (ESD). However, little is known about the diagnostic yield of CT scans for tumors that recurred after curative resection by ESD.

Methods

A total of 1,175 mucosal gastric cancers treated by ESD between January 2007 and December 2012 were retrospectively reviewed. Of them, 894 initial-onset early gastric cancers with two or more endoscopies with biopsy and one or more CT scans were included for survival analysis.

Results

The median follow-up period was 19.7 months (interquartile range, 11.3–35.4 months), during which time 81 lesions recurred. Of these, 35 recurred as an adenoma, whereas the others recurred as cancer. Of the 81 lesions that recurred, 79 were not diagnosed by abdominal CT scan but rather by endoscopy with biopsy. The remaining two lesions, which recurred as metachronous cancers, had suspicious CT scan findings, such as focal gastric wall thickening. The lesions also were confirmed by endoscopic biopsy, which was performed on the same day. None of the lesions was diagnosed by CT scan before pathologic confirmation by endoscopic biopsy.

Conclusions

Computed tomography scan has a minor role for the surveillance of mucosal gastric cancer after complete resection by ESD. Endoscopy with biopsy should be the primary surveillance option after ESD.     

Laparoscopic ultrasound-guided resection of gastric submucosal tumors

Background The laparoscopic resection of gastric stromal tumors is being performed with increased frequency. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. Methods We report three cases of gastric submucosal tumors treated by a laparoscopic wedge resection of the stomach. All lesions were localized anterior gastric wall by intraoperative ultrasound on the. In the first patient the resection was performed with an endoscopic stapler; in the other patients, ultrasonic coagulation in association with an intracorporeal suture has been used. Results All patients were successfully treated laparoscopically; there were no conversions to open surgery. In all cases the operative course was uneventful. The postoperative hospital stay ranged from 6 to 8 days. Conclusions The results suggest that laparoscopic surgery is an adequate strategy for gastric submucosal neoplasms including gastrointestinal stromal tumors (GIST). Intraoperative ultrasound is very useful in the selection of the technical approach with or without the endoscopic stapler. This article contains a supplementary video.     

Endoscopic submucosal dissection for early gastric cancer using a cross-counter technique

Background and study aims

Endoscopic submucosal dissection (ESD) in early gastric cancer has rapidly come into widespread use. However, since complications such as bleeding and perforation often occur, and the procedure time is longer for ESD than endoscopic mucosal resection (EMR), development of safer and more reliable technique is required.

Patients and methods

The subjects comprised 45 patients with lesions diagnosed histologically as early gastric cancer. They were divided into three groups: cross-counter technique group (CC, n?=?15), peroral traction-assisted ESD with suture material group (PT, n?=?15), and no-traction group (NT, n?=?15). ESD was carried out by two endoscopists who had experienced fewer than 30 cases of ESD. To compare safety and efficacy of a new traction method (CC group) for ESD in early gastric cancer with other methods (PT group and NT group), procedure time, dissected area per unit time, complete resection rate, perforation rate, and bleeding rate were evaluated.

Results

There was no significant difference among these three groups in terms of complications, complete resection rate or procedure time. The dissection area per unit time was 22.4, 15.7, and 13.5?mm²/min in the CC, PT, and NT groups, respectively, and there was a significant difference between the CC and NT groups (p?=?0.007).

Conclusions

The cross-counter technique shortened the treatment time for endoscopists without abundant experience in gastric ESD, and it is considered a useful method to institute in order to introduce ESD.