Endoscopic Mucosal Resection (EMR) of Early Gastric Cancer

Abstract: We conducted this study to clarify the effectiveness of aspiration endoscopic mucosal resection (EMR) using a cap-fitted scope for early gastric cancer in the C and M regions of the stomach. EMR was performed in 111 early gastric cancer patients with 123 lesions in the C and M regions. The patients were divided into three groups. The EMR-1CS group consisted of patients who had undergone EMR with a one-channeled scope, the EMR-2CS group those who had received EMR in which a two-channeled scope was utilized. The EMRC group consisted of patients who had undergone aspiration EMR with a cap-fitted scope. The rate of complete resection improved to a statistically significant degree in the EMRC group in comparison with that in the EMR-1CS group. In type lie, a statistically significant improvement was achieved in the EMRC group in comparison with the EMR-2CS group. In the M region or in lesions 10 mm or less in diameter, the rate of complete resection improved in the EMRC group as compared with that in the EMR-2CS group. Our results suggest that EMRC is useful for lesions of early gastric cancer in the C and M regions.     

Laparoscopic Gastrectomy for Early Gastric Cancer after Endoscopic Mucosal Resection

Abstract: In 1991, we first performed a simple technique of Iaparoscopy-assisted Bill-roth I gastrectomy for patients with mucosal gastric cancer. Endoscopic mucosal resection (EMR) sometimes fails to completely resect the early gastric cancer lesion, nor does it give full histopathology of the resected stomach. The aim of this study was to review the surgical and pathological findings of eight patients who underwent laparoscopic gastrectomy after EMR for early gastric cancer. Of 54 patients with early gastric cancer who were treated with laparoscopic gastrectomy between 1994 and 1998, eight patients underwent surgery after EMR. The resected margin of the EMR specimens was positive in three and suspicious in five; and three underwent laparoscopic wedge resection of the stomach, while five underwent Iaparoscopy-assisted distal gastrectomy with regional lymph node dissection. All but one resected stomach had residual cancer tissue in the mucosa or submucosa, and three patients had multiple gastric cancers. The results indicated that remnant cancer tissue might be present when the resected margin of the EMR specimen was positive or suspicious. Partial resection or distal gastrectomy under laparoscopy is useful for such patients who have undergone EMR for early gastric cancer. (Dig Endooc 1999; 11:132–136)     

Endoscopic Mucosal Resection for Esophageal Cancer: EMR‐C Procedure

As a therapeutic modality for superficial esophageal cancer, endoscopic mucosal resection (EMR) is now thoroughly established. We routinely perform EMR using a cap (EMR‐C) procedure as a developer. In EMR‐C procedure, injection of a large volume of saline and a certain prelooping along the inner rim of the cap are vital issues for safe and reliable resection. In multi‐sessions of EMR, submucosal injection of saline prior to every session is essential, in order to avoid perforation. In such a manner, total circumferential EMR can be performed safely and easily by the EMR‐C procedure.     

Effectiveness of Radical Surgery after Incomplete Endoscopic Mucosal Resection for Early Colorectal Cancers: A Clinical Study Investigating Risk Factors of Residual Cancer

The aim of this study was to determine the need for additional treatment following endoscopic mucosal resection for early colorectal cancer. Risk factors for residual carcinoma were investigated using specimens of curative surgical resection performed after endoscopic mucosal resection. A total of 44 patients who had received imperfect endoscopic mucosal resection initially for early colorectal cancers and, therefore, had undergone subsequent surgical resection were enrolled in this study. Of these, 39 (88.6%) were resected completely by endoscopic mucosal resection based on gross inspection, while the other five cases (11.4%) were incompletely resected. Histopathological examination of specimens of endoscopic mucosal resection revealed that microscopic lateral resection margin was positive in 11 cases (25.0%) and vertical resection margin was positive in 16 cases (36.4%). However, after curative surgery, residual cancer within colorectal tissue was found in only five cases (11.4%), while lymph node metastases were found in three cases (6.8%). Gross incomplete resection (P < 0.001) and microscopic vertical margin positivity (P = 0.031) were found to be risk factors of residual cancer within the colorectal tissue, whereas lymphovascular invasion was a risk factor for lymph node metastasis (P = 0.040). However, no residual cancer cells were found after supplementary surgery in the microscopic lateral resection margin-positive cases. In conclusion, grossly incomplete resection, microscopic vertical resection margin positivity, or the presence of lymphovascular invasion after endoscopic mucosal resection for early colorectal cancer indicate the need for further treatment with surgical resection and lymph node dissection. However, microscopic lateral margin positivity without gross remnant tumor and deep submucosal invasion might not indicate residual cancer. This needs to be further validated by a large scale, prospective study with long-term follow-up.     

Endoscopic Therapy of Early Gastric Cancer —Comparison of Endoscopic Mucosal Coagulation and Resection—

Abstract: The clinical efficacy of various methods of endoscopic treatment was evaluated in 70 patients with early gastric cancer. The treatments included using an Nd- YAG laser on 22 patients (2 IIa cases, 3 IIa + IIc cases and 17 IIc cases), a heater probe on 2 patients (IIc) and endoscopic mucosal resection (EMR) on 46 patients (13 I cases, 15 IIa cases, 2 IIa + IIc cases and 16 IIc cases). Laser irradiation and the heater probe method (endscopic mucosal coagulation; EMC), which cause coagulation and necrosis to lesions using heat energy, were found to be successful for well differentiated adenocarcinoma confined to the mucosa even if the size of the lesions was 20 mm and over. Poorly differentiated adenocarcinoma with lesions 20 mm or smaller reoccurred, and only well differentiated adenocarcinoma with infiltration limited to the mucosa seemed to be treatable endoscopically by EMR. Whether or not total resection was possible was determined with respect to the size and site of lesions in patients treated by EMR. Great therapeutic efficacy was achieved when the lesions were 10 mm or smaller and located in the anterior wall or the greater curvature. Piecemeal resection had to be made in a majority of cases when the lesions measured 10 mm or more or were located in the lesser curvature or the posterior wall. Therefore, endoscopic EMR is recommended if the size of the lesions is 10 mm or less, while EMC must also be considered if the lesions are larger or piecemeal resection is required.     

The Results of Questionnaire about Endoscopic Mucosal Resection in the Stomach

Isolated exfoliation method of gastric endoscopic mucosal resection (EMR) as a new technique has not yet reached the popularity of the conventional EMR techniques. From the results of a questionnaire about EMR in the stomach, the isolated exfoliation method has the advantage of permitting en bloc and histologically complete resection regardless of lesion size. However, this method has the disadvantage of long performance time and high frequency of complication as well as the need for a high level of technical skill. New devices and ideas are needed for the development of the isolated exfoliation method.     

Enodscopic Mucosal Resection for Gastric Cancer: Necessity of ‘Incision and Stripping Method’ and Present Status

Endoscopic mucosal resection (EMR) was developed in the early 1980s and has been employed widely as a radical treatment for certain groups of early gastrointestinal cancer because of its lower invasiveness, cost effectiveness, and short hospital stay. In the late 1990s extension of its indication has been discussed and several data allow us to perform EMR in wide lesions more than with conventional indications. However, using conventional EMR such as the 2‐channel method, cap method, etc. it becomes difficult to remove lesions more than 2 cm en bloc. Then ‘incision and stripping’, such as insulated‐tipped diathermic knife (IT knife), needle knife with doom food, flex‐knife, and hook knife were also developed. Using these techniques, it becomes feasible to remove larger lesions more than 2 cm en‐bloc. However, in order to improve these techniques it is necessary to perform a large number of the procedures.     

Endoscopic treatment for early gastric cancer

Gastric cancer remains one of the most common causes of cancer death.However the proportion of early gastric cancer(EGC)at diagnosis is increasing.Endoscopic treatment for EGC is actively performed worldwide in cases meeting specific criteria.Endoscopic mucosal resection can treat EGC with comparable results to surgery for selected cases.Endoscopic submucosal dissection(ESD)increases the en bloc and complete resection rates and reduces the local recurrence rate.ESD has been performed with expanded indication and is expected to be more widely used in the treatment of EGC through the technological advances in the near future.This review will describe the techniques,indications and outcomes of endoscopic treatment for EGC.     

Efficacy and Safety of Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients with Comorbid Diseases

Background/Aims

Endoscopic submucosal dissection (ESD), a new and potentially curative method for treating gastrointestinal neoplasms, may have longer procedure time and the risk of complications when compared to conventional endoscopic mucosal resection. This study evaluated the efficacy and safety of ESD in patients with comorbid diseases.

Methods

The outcomes of 337 patients who underwent ESD for early gastric cancer at Samsung Medical Center from April 2003 to December 2006 were analyzed retrospectively. The Charlson comorbidity scale was used to divide the patients into low-risk (no risk factor) and high-risk (at least one risk factor) groups. The outcomes and complications were compared between the high- and low-risk groups.

Results

The low- and high-risk groups comprised 240 and 97 patients with mean ages of 61.1 and 64.7 years, respectively (p=0.002). Tumor location, tumor size, depth of invasion, procedure duration, and rates of en bloc resection, complete resection, complication, and recurrence did not differ significantly between the two groups (p>0.05).

Conclusions

ESD may be a safe and effective treatment for early gastric cancer in patients with comorbid diseases.     

Upgrade of Lesions Initially Diagnosed as Low-Grade Gastric Dysplasia upon Forceps Biopsy Following Endoscopic Resection

Background/Aims

Gastric dysplasia is generally accepted to be the precursor lesion of gastric carcinoma. Approximately 25% to 35% of histological diagnoses based on endoscopic forcep biopsies for gastric dysplastic lesions change following endoscopic resection (ER). The aim of this study was to determine the predictive endoscopic features of high-grade gastric dysplasia (HGD) or early gastric cancer (EGC) following ER for lesions initially diagnosed as low-grade dysplasia (LGD) by a forceps biopsy.

Methods

To determine predictive variables for upgraded histology (LGD to HGD or EGC). The lesion size, gross endoscopic appearance, location, and surface nodularity or redness as well as the presence of a depressed portion, Helicobacter pylori infection, and intestinal metaplasia were retrospectively investigated.

Results

Among 251 LGDs diagnosed by an initial forceps biopsy, the diagnoses of 100 lesions (39.8%) changed following the ER; 56 of 251 LGDs (22.3%) were diagnosed as HGD, 39 (15.5%) as adenocarcinoma, and 5 (2.0%) as chronic gastritis. In a univariate analysis, large lesions (>15 mm), those with a depressed portion, and those with surface nodularity were significantly correlated with a upgraded histology classification following ER. In a multivariate analysis, a large size (>15 mm; odds ratio [OR], 2.8; 95% confidence interval [CI], 1.46 to 5.43) and a depressed portion in the lesion (OR, 2.7; 95% CI, 1.44 to 5.03) were predictive factors for upgraded histology following ER.

Conclusions

Our study shows that a substantial proportion of diagnoses of low-grade gastric dysplasias based on forceps biopsies were not representative of the entire lesion. We recommend ER for lesions with a depressed portion and for those larger than 15 mm.     

Prospect of Endoscopic Mucosal Resection for Early Gastric Cancer: Our Devices in Insulated‐Tip Electrosurgical Knife Method

In Kobe University Hospital, a new method for endoscopic mucosal resection (EMR) using insulated‐tip electrosurgical knife (IT‐EMR) for early gastric cancer (EGC) was introduced from November 2001. To achieve an effective and safe IT‐EMR procedure, we use a high‐frequency surgical unit for cutting and coagulation (ERBOTOM ICC 200) with automatically controlled cutting mode (ENDOCUT). In this study, we show not only our results of IT‐EMR for EGC in comparison with those of the conventional strip biopsy method, but also the optimal conditions for the apparatus of a high‐frequency surgical unit to prevent complications such as bleeding and perforation.     

早期胃癌的内镜下治疗

随着内镜技术的不断进步,越来越多的早期胃癌可经内镜下治疗.本文简要地介绍了早期胃癌内镜下治疗的发展史.重点介绍了目前早期胃癌内镜下治疗最先进的方法一黏膜剥离术的特点、适应征、并发症及处理对策.     

Therapeutic Decision-Making Using Endoscopic Ultrasonography in Endoscopic Treatment of Early Gastric Cancer

Background/Aims

We evaluated the effectiveness of an endoscopic ultrasonography (EUS)-based treatment plan compared to an endoscopy-based treatment plan in selecting candidates with early gastric cancer (EGC) for endoscopic submucosal dissection based on the prediction of invasion depth.

Methods

We reviewed 393 EGCs with differentiated histology from 380 patients who underwent EUS from July 2007 to April 2010. The effectiveness of the EUS-based and endoscopy-based plans was evaluated using a simplified hypothetical treatment algorithm.

Results

The numbers of endoscopically determined mucosal, indeterminate, and submucosal cancers were 253 (64.4%), 56 (14.2%), and 84 (21.4%), respectively. Overall, the appropriate treatment selection rates were 75.3% (296/393) in the endoscopy-based plan and 71.5% (281/393) in the EUS-based plan (p=0.184). For endoscopic mucosal cancers, the appropriate treatment selection rates in the endoscopy-based plan were 88.1% (223/253), while the use of an EUS-based plan significantly decreased this rate to 81.4% (206/253) (p=0.036). For endoscopic submucosal cancers, the appropriate selection rates did not differ between the endoscopy-based plan (46.4%, 39/84) and the EUS-based plan (53.6%, 45/84) (p=0.070).

Conclusions

EUS did not increase the likelihood of selecting the appropriate treatment in differentiated-type EGC. Therefore, EUS may not be necessary before treating differentiated-type EGC, especially in endoscopically presumed mucosal cancers.     

Long-term Outcomes of Undifferentiated-Type Early Gastric Cancer with Positive Horizontal Margins after Endoscopic Resection

Background/AimsThis study examined the long-term outcomes of undifferentiated-type early gastric cancer (UD EGC) with positive horizontal margins (HMs) after endoscopic resection (ER) and compared them between additional surgery and nonsurgical management.MethodsFrom 2005 to 2015, a total of 1,124 patients with UD EGC underwent ER at 18 tertiary hospitals in Korea. Of them, 92 patients with positive HMs as the only noncurative factor (n=25) or with both positive HMs and tumor size >2 cm (n=67) were included. These patients underwent additional surgery (n=40), underwent additional endoscopic treatment (n=6), or were followed up without further treatment (n=46).ResultsNo lymph node (LN) metastasis was found in patients who underwent additional surgery. During a median follow-up of 57.7 months (interquartile range, 27.6 to 68.8 months), no LN or distant metastases or gastric cancer-related deaths occurred in the overall cohort. At baseline, the residual cancer rate was 57.8% (26/45) after additional surgery or ER. The 5-year local recurrence rate was 33.6% among patients who were followed up without additional treatment. The 5-year overall survival rates were 95.0% and 87.8% after additional surgery and nonsurgical management (endoscopic treatment or close follow-up), respectively (log-rank p=0.224). In the multivariate Cox regression analysis, nonsurgical management was not associated with an increased risk of mortality.ConclusionsUD EGC with positive HMs after ER may have favorable long-term outcomes and a very low risk of LN metastasis. Nonsurgical management may be suggested as an alternative, particularly for patients with old age or chronic illness. (Gut Liver 2021;15-731)     

Endoscopic Mucosal Resection of Early Esophageal Cancers: Our Method

Though endoscopic mucosal resection (EMR) may provide definitive treatment for selected cases of early esophageal carcinoma, the standard method has not been determined yet. There have been several EMR techniques so far developed, including strip biopsy, EMR using a cap, Makuuchi tube method, etc. The selection of EMR method largely depends on personal experience and preference of an endoscopist. Here we present our EMR method along with its advantages and disadvantages. With the extension of indications, more cases of early esophageal cancer will be treated by EMR. Since only long‐term results tell what the ideal EMR method is, well‐designed comparative studies are necessary in the future to establish a standard method.     

26例早期胃癌的内镜下诊断及治疗分析

目的分析早期胃癌的内镜下诊断及治疗经验。方法对2010年1月-2012年8月我院发现的26例早期胃癌患者的资料回顾性总结和分析,均行普通胃镜下扫查、病灶区NBI染色、美兰染色,直视下活检确诊,以超声胃镜判断病灶浸润深度,选择EMR和ESD进行内镜下治疗。结果 26例患者,男女比例为1.89∶1,55岁以上占69.2%,部位以胃窦部好发,腺癌合并高级别上皮内瘤变多见,胃镜分型以Ⅱc+Ⅲtype最多(69.2%),NBI加美兰染色后均不同程度染色异常。超声内镜均见黏膜层不同程度增厚。EMR、ESD治疗后,完全清除者占96.2%。结论认真仔细操作规范及应用多种检查技术可提高早期胃癌检出率,推广内镜下早期胃癌治疗技术安全、有效。     

IT刀在内镜黏膜切除术中的应用

内镜下黏膜切除术因其完全切除率高,并发症及复发率极低,目前在许多国家已被作为治疗早期消化道肿瘤的标准方法.然而,应用传统的EMR技术,很难将肿瘤组织整块切除.近年来在日本研制出一系列新型的手术刀,较成功地解决了这一难题.全文主要介绍末端绝缘手术刀(IT刀)在内镜下黏膜切除术中的应用,包括适应证、操作方法、切除效果的判定等方面.     

Accuracy of Endoscopic Ultrasonography for Determining the Depth of Invasion in Early Gastric Cancer

Background:Accurate staging for depth of invasion (T stage) of early gastric cancer is critical for determining the treatment modality. Endoscopic ultrasonography is a reliable method for assessing the T stage. However, its diagnostic accuracy varies. The aim of this study is to investigate clinicopathologic factors affecting the diagnostic accuracy of endoscopic ultrasonography in early gastric cancer.Methods:Patients with early gastric cancer who had undergone endoscopic resection or gastrectomy were included. The diagnostic accuracy of endoscopic ultrasonography was evaluated by comparing the T stage by endoscopic ultrasonography with histopathology of the resected specimen. Subgroup analysis was performed according to the endoscopic resection criteria.Results:A total of 223 early gastric cancer lesions were included. The overall accuracy of endoscopic ultrasonography for T staging was 66.4%. The diagnostic accuracy for lesions ≤2 cm was significantly higher than for those of 2-3 cm (odds ratio 3.59) or those >3 cm (odds ratio 5.47). The diagnostic accuracy was significantly decreased in lesions with ulceration (odds ratio 2.62) or non-flat morphology (odds ratio 2.94). The accuracy of endoscopic ultrasonography for lesions corresponding to the absolute endoscopic resection criteria was significantly higher than for those corresponding to the expanded criteria (97.3% vs 71.9%, P = .002). Of the tumors that were overestimated by endoscopic ultrasonography treated with gastrectomy, 93.3% corresponded to the expanded criteria.Conclusion:Endoscopic ultrasonography had poor accuracy in early gastric cancer lesions larger than 2 cm, those with ulceration, and those with non-flat morphology, that is, lesions corresponding to the expanded criteria were more frequently overstaged by endoscopic ultrasonography. Such early gastric cancers should be carefully considered when staging by endoscopic ultrasonography before gastrectomy.     

Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: A meta-analysis

AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Schol-ar and Cochrane library databases. Quality of each included study was assessed according to current Co-chrane guidelines. Primary endpoints were en bloc re-section rate and histologically complete resection rate. Secondary endpoints were length of procedure, post-treatment bleeding, post-procedural perforation and re-currence rate. Comparisons between the two treatment groups across all the included studies were performed by using Mantel-Haenszel test for fixed-effects mod-els(in case of low heterogeneity) or DerSimonian and Laird test for random-effects models(in case of high heterogeneity).RESULTS: Ten retrospective studies(8 full text and 2 abstracts) were included in the meta-analysis. Overall data on 4328 lesions, 1916 in the ESD and 2412 in the EMR group were pooled and analyzed. The mean operation time was longer for ESD than for EMR(stan-dardized mean difference 1.73, 95%CI: 0.52-2.95, P =0.005) and the "en bloc " and histological complete re-section rates were significantly higher in the ESD group [OR = 9.69(95%CI: 7.74-12.13), P 0.001 and OR = 5.66,(95%CI: 2.92-10.96), P 0.001, respectively]. As a consequence of its greater radicality, ESD provided lower recurrence rate [OR = 0.09,(95%CI: 0.05-0.17), P 0.001]. Among complications, perforation rate was significantly higher after ESD [OR = 4.67,(95%CI, 2.77-7.87), P 0.001] whereas the bleeding incidences did not differ between the two techniques [OR = 1.49(0.6-3.71), P = 0.39].CONCLUSION: In the endoscopic therapy of EGC, ESD showed a superior efficacy but higher complication rate with respect to EMR.