Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer

BACKGROUND: Endoscopic mucosal resection is an established treatment option for early stage gastric cancer. However, several problems with endoscopic mucosal resection remain to be solved, such as appropriate treatment for recurrence and incomplete tumor resection. The outcome for patients undergoing endoscopic aspiration mucosectomy (endoscopic mucosal resection) by a modification of the cap-fitted technique was evaluated retrospectively to determine factors associated with complete resection and tumor recurrence. METHODS: Endoscopic mucosal resection was performed in 106 patients with early stage gastric cancers up to 20 mm in diameter that were well or moderately differentiated adenocarcinoma. All were superficial lesions without ulceration, distinct signs of submucosal invasion, or a poorly demarcated border. En bloc (tumors <10 mm in diameter) or piecemeal (tumors 10-20 mm in diameter) resection was performed. Follow-up endoscopy was performed at 2, 6, 12, 18, and 24 months and thereafter once per year. Outcome and factors associated with complete resection and tumor recurrence were assessed retrospectively. RESULTS: Sixty-eight patients (64%) underwent en bloc resection and 38 (36%) piecemeal resection. The mean longest dimension (SD) of the resected lesions was significantly greater after piecemeal resection (12.3 [4.0] mm) than after en bloc resection (7.6 [4.0] mm; p < 0.01). In patients with tumors completely resected, there was no recurrence after either en bloc or piecemeal resection. Six of 8 patients found to have submucosal invasion after endoscopic mucosal resection underwent surgery. Patients with incompletely resected intramucosal lesions underwent additional endoscopic treatment. Cancer recurred in 3 patients (2.8%), all of whom had lesions measuring more than 15 mm in diameter. CONCLUSIONS: Endoscopic mucosal resection is safe and useful for the management of early stage gastric cancer. Further improvement in outcome requires more accurate preoperative diagnosis and postoperative histopathologic evaluation. Patients with incompletely resected lesions should undergo aggressive additional treatment.     

High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of high-frequency probe EUS (HFPE)-assisted endoscopic mucosal resection in the management of submucosal tumors of the GI tract. METHODS: HFPE-assisted endoscopic mucosal resection was attempted in 28 patients with submucosal tumors less than 2 cm in diameter. HFPE was performed with a 20-MHz "through-the-scope" probe. Saline solution was injected into the submucosa. After confirming detachment of the lesion from the muscularis propria by repeat HFPE, endoscopic mucosal resection was performed with a lift-and-cut or endoscopic mucosal resection cap technique. Follow-up endoscopy was performed in all patients. RESULTS: Submucosal tumors from the following areas were included: esophagus 3, stomach 4, duodenum 3, and colon 18. The submucosal tumors were located in the upper third (n = 3), middle third (n = 18), and lower third (n = 7) of the submucosa. Twenty-one submucosal tumors were removed by the lift-and-cut technique and 6 by the cap method. One patient required surgical resection after unsuccessful endoscopic mucosal resection. The origin and depth of penetration of all lesions was accurately depicted by HFPE. Median tumor diameter was 9 mm (range 3-20 mm). Resection was successful and complete in 93% of the cases. There were no immediate postprocedure complications (exact 95% CI [0%, 12.3%]). During a median follow-up of 21.5 months (range 2-74 months) no recurrence was found. CONCLUSIONS: HFPE-assisted endoscopic mucosal resection is safe and effective for the management of selected submucosal tumors of the GI tract. A management algorithm based on endoscopic and HFPE findings is proposed.     

Endoscopic resection for gastrointestinal neuroendocrine tumors

Gastrointestinal (GI) and neuroendocrine tumors (NETs) can be treated by mini-invasive endoscopic resection when localized in the superficial layers of the bowel wall and their size is <20 mm. Endoscopic diagnosis of NETs is usually incidental or suspected after clinical, laboratory or imaging findings. Endoscopic mucosal resection is the most commonly used technique for NET removal, endoscopic submucosal dissection is indicated in selected cases, while papillectomy is feasible for ampullary lesions. Histopathologic assessment of the resection margin (circumferential and deep) is important for staging. Incidence of endoscopic mucosal resection-/endoscopic submucosal dissection-related complications for removal of GI NETs are similar to those reported for other GI lesions. Endoscopic follow-up is based on histopathologic characteristics of the resected NETs and its site. NETs >20 mm in size, with penetration of the muscle layer and/or serosa are at high risk for metastases and surgical approach is recommended when feasible.     

Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett's esophagus

BACKGROUND: Endoscopic mucosal resection has been used in the treatment of superficial squamous cell cancers and gastric malignancies. Our aim was to determine whether endoscopic mucosal resection can be used in the diagnosis of lesions within Barrett's esophagus whose endoscopic appearances raise suspicion of carcinoma or high-grade dysplasia. METHODS: Twenty-five patients with such lesions within Barrett's esophagus underwent endoscopic mucosal resection for diagnostic and therapeutic purposes. All patients underwent endoscopic ultrasound to determine the feasibility of endoscopic resection. Only lesions found to be uT0 or uT1 underwent EMR. The lift and cut technique was used in 23 patients and a variceal ligating device was used on 2 patients. RESULTS: Endoscopic mucosal resection was performed because of a nodule or polyp within Barrett's esophagus in 11 patients (44%) and suspected superficial cancer or high-grade dysplasia in 14 patients (56%). Endoscopic mucosal resection diagnosed superficial adenocarcinoma in 13 patients (52%) and high-grade dysplasia in 4 (16%); it confirmed lesions in 8 patients (40%) to be of lower neoplastic risk. No complications occurred due to the procedure itself. CONCLUSIONS: Endoscopic mucosal resection is a technique with low morbidity and mortality. It has led to a change in diagnosis in patients with Barrett's esophagus and lesions with endoscopic features that suggest neoplasia. Its major advantages include simplicity and retrieval of the specimen en bloc.     

Advantages of endoscopic submucosal dissection over conventional endoscopic mucosal resection

BACKGROUND: Endoscopic mucosal resection is an established method for treating intramucosal gastric neoplasms. Conventional endoscopic mucosal resection has predominantly been performed using strip biopsy, but local recurrence sometimes occurs due to such piecemeal resection. Endoscopic submucosal dissection has recently been performed in Japan using new devices such as an insulation-tip diathermic knife. The efficacy and problems associated with endoscopic submucosal dissection were evaluated by comparison with conventional endoscopic mucosal resection. METHODS: Treatment consisted of conventional endoscopic mucosal resection for 48 lesions from January 1999 to October 2002, and endoscopic submucosal dissection for 59 lesions from November 2002 to June 2005. Endoscopic submucosal dissection was performed using an insulation-tip diathermic knife and flex and hook knives, as appropriate. RESULTS: For lesions >or=11 mm in size, en bloc resection rates were significantly higher with endoscopic submucosal dissection than with conventional endoscopic mucosal resection, but treatment time was significantly longer. En bloc resection rates were higher with endoscopic submucosal dissection than with conventional endoscopic mucosal resection in all areas. Treatment of lesions in the upper one-third of the stomach took a long time using endoscopic submucosal dissection, and intraoperative bleeding was frequent. However, en bloc resection rates and intraoperative bleeding with endoscopic submucosal dissection were improved using various knives. CONCLUSIONS: Endoscopic submucosal dissection can take a long time, but is superior to conventional endoscopic mucosal resection for treating intramucosal gastric neoplasms.     

20-MHz high-frequency endoscopic ultrasound-assisted endoscopic mucosal resection for colorectal submucosal lesions: a prospective analysis

GOALS: To prospectively assess the safety and efficacy of high-frequency ultrasound assisted mini-probe endoscopic mucosal resection for the treatment of colorectal submucosal tumors. Primary endpoints were tumor free vertical/horizontal resection margins and positive histopathologic diagnosis. Outcome data over a 24-month period were assessed. BACKGROUND: A 20-MHz high-frequency mini-probe ultrasound is an accurate modality for the diagnosis of stage T1m and T1 colorectal lesions. Few studies have addressed the safety and efficacy of this technology as applicable to submucosal lesions of the colorectum. METHODS: Thirty patients underwent high-frequency mini-probe ultrasound-guided endoscopic mucosal resection of 30 lesions (<20 mm diameter) using the inject and cut technique. Repeat endoscopy and ultrasound was performed at 3, 6, and 12 months post-"index" resection. RESULTS: A total of 27 lesions (90%) underwent complete resection with negative histologic margin status (median diameter, 8 mm; range, 3-20 mm). No statistical difference (P > 0.1) was observed between submucosal lesion position and histologic resection margin negativity. Three rectal lesions (10%) within the submucosal layer 3 failed to separate from the muscularis and underwent transanal excision of tumor. Bleeding occurred in 1 patient (3%). No recurrence was evident at the resection site in 27 cases (median follow-up, 9 months; range, 4-18 months). CONCLUSIONS: High-frequency mini-probe ultrasound-guided endoscopic mucosal resection is a safe and effective therapeutic modality for submucosal lesions of the colorectum. The technique offers a single-stage diagnostic and therapeutic technique for selected submucosal lesions and may offer an alternative to surgical resection.     

Effectiveness of endoscopic mucosal resection with submucosal saline injection technique for superficial squamous carcinomas of the esophagus

BACKGROUND: Intraepithelial cancers (m1 cancer) and cancers that penetrate the basement membrane but do not approach the muscularis mucosae (m2 cancer) do not have lymph node metastasis and thus can be removed completely with mucosal resection. Therefore, in this study, the effectiveness of endoscopic mucosal resection with submucosal saline injection for removal of superficial esophageal cancers was investigated prospectively. METHODS: Twenty-five superficial esophageal cancers in 21 patients were removed with submucosal saline injection. When it was thought that a tumor had not been completely resected en bloc, it was removed completely in piecemeal fashion. Endoscopy was repeated 1, 3, 6, 12 months or more after endoscopic resection. RESULTS: All superficial esophageal cancers were completely removed: 18 (72%) en bloc and 7 (28%) by piecemeal resection. No recurrence was found during a mean observation period of 2.0 years (range 0.8 to 3.6) after resection. Bleeding occurred in 5 cases (24%) during or after resection but was successfully treated with the endoscopic alginate or thrombin spray technique. There was no perforation. CONCLUSION: Endoscopic mucosal resection with submucosal saline injection is effective for removal of superficial cancers of the esophagus.     

Endoscopic mucosal resection for colorectal neoplastic lesions

PURPOSE: Endoscopic mucosal resection, which is a new option for endoscopic polypectomy of colorectal polyps without stalks, was evaluated on its usefulness in polypectomy. METHODS: Three hundred thirty-seven lesions, which were removed by endoscopic mucosal resection between January 1990 and January 1993, were studied. The endoscopic configuration of neoplastic lesions were classified into four types: flat, sessile, large sessile with distinct lobulations, and semipedunculated. RESULTS: The 337 lesions included 243 adenomas, 30 mucosal cancers, 13 submucosal cancers, 3 carcinoids, 43 hyperplastic polyps, and 5 inflammatory polyps. Of the 286 neoplastic lesions, excluding 3 carcinoids, 137 were flat, 81 were sessile, 18 were large sessile, and 50 were semipedunculated. The 137 flat lesions consisted of 125 adenomas, 10 mucosal cancers, and 2 submucosal cancers. The rate of complete removal was related to their size and configuration and was 87 percent in flat neoplastic lesions. Lesion diameters of greater than 20 mm and the large sessile-type configurations were factors that were associated with incomplete removal. Two (0.7 percent) cases were complicated by perforations, and one (0.4 percent) case was complicated by bleeding. CONCLUSION: Endoscopic mucosal resection is an useful option for complete removal of colorectal nonpolypoid adenomas and cancers.     

Submucosal endoscopy: a novel approach to en bloc endoscopic mucosal resection (with videos)

BACKGROUND: The submucosal layer is of eminent importance for endoscopic mucosal resection (EMR) in the GI tract. OBJECTIVE: Development of submucosal endoscopy, which allows diagnostic and therapeutic endoscopy of the submucosal space (SS) in the esophagus. DESIGN: Acute experiments in a live porcine model. INTERVENTIONS: An area in the esophagus was marked with a diathermic probe to define a mucosal piece for resection. After local infiltration, a 1- to 2-cm transverse incision was performed 1 to 2 cm proximal and distal of these margins. We entered the SS with a flexible small-caliber videoendoscope through the proximal incision and dissected the fibrous submucosal connective tissue in a longitudinal direction with a blunt forceps. For EMR, the lifted mucosa was subsequently separated by use of an insulated-tip hook needle-knife. MAIN OUTCOME MEASUREMENTS: En bloc resection of prespecified mucosal areas. RESULTS: A total of 15 mucosal pieces were resected in 4 pigs. The size of the resected pieces varied from 1.6 cm x 0.9 cm to 7.4 cm x 1.7 cm ex vivo. In a fifth pig, 2 circular mucosectomies (lengths 3.0 cm and 1.6 cm) were done. All mucosal pieces could be completely resected en bloc. The endoscopic view in the SS was excellent. There were no procedure-related complications. LIMITATIONS: The method has not yet been evaluated in humans. CONCLUSIONS: Entering the SS for submucosal endoscopy is a novel, innovative, and practicable method for the dissection of mucosal neoplastic lesions. We demonstrated that mucosal areas of various sizes could be resected en bloc without complications.     

Endoscopic mucosal resection of colorectal tumors

It has been possible to resect early colorectal cancer by endoscopy due to the progress of colonoscopic diagnosis and technology. Therefore, most cases of colorectal mucosal cancer and benign tumor have been resected by endoscopy only. We report some techniques for endoscopic resection of colorectal tumors. The technique of endoscopic resection: (i) The B‐Wave bipolar snare device: It is difficult to resect flat lesions that are not sufficiently elevated to be ligated by a usual snare. The snare of the B‐Wave bipolar snare device is coated to prevent slipping on the colorectal mucosa. (ii) ‘Sculpting down’ polypectomy: It is difficult to resect large sessile lesions because the bases of these lesions cannot be well observed endoscopically. ‘Sculpting down’ polypectomy is a useful method for safe resection of such tumors. (iii) Endoscopic resection through a retroflexed scope: Under retroverted colonoscopic observation, submucosal injection and partial resection is performed. Then, under ordinary observation, complete resection of the residual tumor is performed. (iv) Endoscopic mucosal resection using a cap‐fitted panendoscope (EMRC): EMRC is useful for lesions located in the lower rectum because there is no risk of free perforation. At first, submucosal injection is performed. The snare is set in the transparent cap and the lesion is aspirated into the cap. Then, it is snared and resected.     

Usefulness and safety of 0.4% sodium hyaluronate solution as a submucosal fluid "cushion" in endoscopic resection for gastric neoplasms: a prospective multicenter trial

BACKGROUND: Sodium hyaluronate (SH) solution has been used for submucosal injection in endoscopic resection to create a long-lasting submucosal fluid "cushion." OBJECTIVES: Our purpose was to assess the usefulness and safety of 0.4% SH solution in endoscopic resection. DESIGN: A prospective multicenter randomized controlled trial. SETTING: Six referral hospitals in Japan. PATIENTS: One hundred forty patients with 5- to 20-mm gastric intramucosal neoplastic lesions. INTERVENTIONS: Patients were randomized into 0.4% SH and control groups. Endoscopic resection was performed with 0.4% SH or normal saline solution for submucosal injection. MAIN OUTCOME MEASUREMENTS: Primary outcome measure: The usefulness of 0.4% SH solution was assessed by en bloc complete resection and the formation and maintenance of mucosal lesion-lifting during endoscopic resection. Secondary outcome measures: (1) steepness of mucosal lesion lifting, (2) complications, (3) time required for mucosal resection, (4) volume of submucosal injection solution, and (5) ease of mucosal resection. Safety was assessed by analyzing adverse events during the study period. RESULTS: The usefulness rate was significantly higher for the 0.4% SH group (88.4%, 61/69) than for the control group (58.6%, 41/70). As secondary outcome measures, significant intergroup differences (P < .001) were noted for (1) steepness of mucosal lesion lifting, (2) volume of submucosal injection solution, and (3) ease of mucosal resection. No serious adverse events were encountered in either group. LIMITATIONS: Lack of blinding. Safety was not a powered outcome measure. CONCLUSIONS: Using 0.4% SH as a submucosal injection solution in endoscopic resection enabled the formation and maintenance of sufficient mucosal lesion lifting for gastric intramucosal lesions, reducing the need for additional injections and simplifying mucosal resection. Use of 0.4% SH thus simplifies the complicated procedures involved in endoscopic resection.     

Management of local recurrence after endoscopic resection of neoplastic colonic polyps

A proportion of neoplastic polyps are incompletely resected, resulting in local recurrence, especially after resection of large polyps or piecemeal resection. Local recurrences that develop after endoscopic resection of intramucosal neoplasms that lacked risk factors for lymph node metastasis or positive vertical margins are usually treated endoscopically. Endoscopic submucosal dissection(ESD) is indicated for local residual or recurrent early carcinomas after endoscopic resection. However, ESD for such recurrent lesions is technically difficult and is typically a lengthy procedure. Underwater endoscopic mucosal resection(UEMR), which was developed in 2012, is suitable for recurrent or residual lesions and reportedly achieves superior en bloc resection rates and endoscopic complete resection rates than conventional EMR. However, a large recurrent lesion is a negative independent predictor of successful en bloc resection and of complete endoscopic removal. We therefore perform UEMR for relatively small(≤ 10-15 mm) recurrent lesions and ESD for larger lesions.     

Rectal laterally spreading tumors successfully treated in two steps by endoscopic submucosal dissection and endoscopic mucosal resection

Background  

Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy alternative to endoscopic mucosal resection (EMR) for superficial gastrointestinal neoplasms >2 cm. ESD allows for the direct dissection of the submucosa and large lesions can be resected en bloc. ESD is not limited by resection size, increases histologically complete resection rates and may reduce the local recurrence.     

Management of Early-Stage Adenocarcinoma of the Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Barrett’s esophagus with high-grade dysplasia and early-stage adenocarcinoma is amenable to curative treatment by endoscopic resection. Histopathological correlation has established that mucosal cancer has minimal risk of nodal metastases and that long-term complete remission can be achieved. Although surgery is the gold-standard treatment once there is submucosal involvement, even T1sm1 (submucosal invasion?≤?500 μm) cases without additional risk factors for nodal metastases might also be cured with endoscopic resection. Endoscopic resection is foremost an initial diagnostic procedure, and once histopathological assessment confirms that curative criteria are met, it will be considered curative. Endoscopic resection may be achieved by endoscopic mucosal resection, which, although easy to perform with relatively low risk, is limited by an inability to achieve en bloc resection for lesions of size more than 1.5 cm. Conversely, the technique of endoscopic submucosal dissection is more technically demanding with higher risk of complications but is able to achieve en bloc resection for lesions larger than 1.5 cm. Endoscopic submucosal dissection would be particularly important in specific situations such as suspected submucosal invasion and lesion size more than 1.5 cm. In other situations, since endoscopic resection would always be combined with radiofrequency ablation to ablate the remaining Barrett’s epithelium, piecemeal endoscopic mucosal resection would suffice since any remnant superficial invisible dysplasia would be ablated.     

Esophageal Mucosal Autograft for Preventing Stricture After Widespread Endoscopic Submucosal Dissection of Superficial Esophageal Lesions

Background: Although esophageal mucosal autograft prevents esophageal stricture after widespread endoscopic submucosal dissection and has been reported as a new technique, it is relatively unproven in clinical practice. This prospective study was conducted to evaluate our experience using esophageal mucosal autograft to prevent strictures after widespread endoscopic submucosal dissection in patients with widespread superficial esophageal lesions.Methods: Between October 2017 and June 2018, 15 patients with widespread superficial esophageal lesions were consecutively treated with widespread endoscopic submucosal dissection and then underwent esophageal mucosal autograft. The main outcomes measured included esophageal epithelialization and esophageal stricture.Results: The median longitudinal diameter of the widespread superficial esophageal lesions was 5.2 cm. All 15 patients were successfully treated with widespread endoscopic submucosal dissection and esophageal mucosal autograft, and the median procedural time was 182 minutes. During follow-up (median, 23 months), esophageal epithelialization was found in 13 patients (86.7%), and 7 patients experienced esophageal stricture (46.7%). In those 7 patients, the esophageal strictures were successfully relieved after endoscopic balloon dilation or endoscopic radial incision. No complications related to endoscopic balloon dilation/endoscopic radial incision occurred. Additionally, local recurrence was found in 1 patient with poorly differentiated squamous cell carcinoma, and further surgical resection was performed.Conclusions: Esophageal mucosal autograft appears to be an efficient approach to reconstructing local esophageal epithelium and might have a potential role in preventing esophageal stricture after widespread endoscopic submucosal dissection. However, as a new technique, it needs more improvement to enhance its role in preventing esophageal stricture after widespread endoscopic submucosal dissection.     

Endoscopic diagnosis and treatment of superficial nonampullary duodenal tumors

The diagnostic and treatment guidelines of superficial non-ampullary duodenal tumors have not been standardized due to their low prevalence.Previous reports suggested that a superficial adenocarcinoma(SAC) should be treated via local resection because of its low risk of lymph node metastasis,whereas a highgrade adenoma(HGA) should be resected because of its high risk of progression to adenocarcinoma.Therefore,pretreatment diagnosis of SAC or HGA is important to determine the appropriate treatment strategy.There are certain endoscopic features known to be associated with SAC or HGA,and current practice prioritizes the endoscopic and biopsy diagnosis of these conditions.Surgical treatment of these duodenal lesions is often related to high risk of morbidity,and therefore endoscopic resection has become increasingly common in recent years.Endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD) are the commonly performed endoscopic resection methods.EMR is preferred due to its lower risk of adverse events;however,it has a higher risk of recurrence than ESD.Recently,a new and safer endoscopic procedure that reduces adverse events from EMR or ESD has been reported.     

Endoscopic submucosal dissection of stomach neoplasms after unsuccessful endoscopic resection

BACKGROUND: Endoscopic submucosal dissection is a novel endoluminal endoscopic surgery that enables resection of pre-malignant and early-stage malignant gastrointestinal neoplasms in an en bloc fashion. AIM: To assess the feasibility of endoscopic submucosal dissection of stomach neoplasms with submucosal fibrosis caused by unsuccessful endoscopic resection. PATIENTS AND METHODS: Stomach endoscopic submucosal dissection was performed in ten consecutive patients who had unsuccessful endoscopic tumour resection at another hospital between 2003 and 2006. Seven patients had recurrent tumours after complete endoscopic resection, and three patients had incomplete resections due to complications or technical difficulties. Technical feasibility and follow-up data were collected from the patients' reports. RESULTS: All tumours were resected by endoscopic submucosal dissection in one piece without complications. R0 resection (en bloc resection with tumour-free margins) was achieved in nine patients (90%). One patient received additional surgery (gastrectomy) because of submucosal deep invasion with vascular infiltration of the cancer. All patients, including the patient with gastrectomy, have survived without recurrence during a mean follow-up period of 21.4 months (range 3-36 months). CONCLUSIONS: Endoscopic submucosal dissection is an effective and safe method for resection of stomach neoplasms after unsuccessful endoscopic resection.     

CLINICAL ADVANTAGES OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC CANCERS IN REMNANT STOMACH SURPASS CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION

Aim: Endoscopic submucosal dissection was developed to address the shortcomings of conventional endoscopic mucosal resection. The present study evaluated the benefits of endoscopic submucosal dissection compared with conventional endoscopic mucosal resection for the treatment of neoplasms arising from the remnant stomach after gastrectomy or esophagectomy. Methods: This study, which was designed as a historical control study, evaluated 22 gastric cancers in remnant cancers treated by conventional endoscopic mucosal resection and another 40 cancers treated by endoscopic submucosal dissection. Results: Patient characteristic between the two groups were not different except for tumor size, which was larger in patients with endoscopic submucosal dissection. The local complete resection rate and the curative resection rate were significantly higher in the endoscopic submucosal dissection group compared to those in the mucosal resection group (95.0% vs 40.9% and 80.0% vs 40.9%, respectively). Complication rate showed no significant difference in the two groups, although submucosal dissection required a longer operation time. Conclusion: Endoscopic submucosal dissection represents a reliable treatment for gastric cancers in the remnant stomach, surpassing endoscopic mucosal resection.     

Endoscopic therapy in patients with Barrett's esophagus and portal hypertension

BACKGROUND: Endoscopic mucosal resection has been used to stage and treat early neoplasia in Barrett's esophagus. The ability to do this in the setting of portal hypertension has not been reported. OBJECTIVE: Our purpose was to describe the feasibility and efficacy of endoscopic mucosal resection in patients with portal hypertension and Barrett's esophagus. DESIGN: Retrospective case series. SETTING: Two tertiary referral centers. PATIENTS: Patients with Barrett's esophagus and high-grade dysplasia or adenocarcinoma in the setting of portal hypertension. INTERVENTION: Endoscopic mucosal resection of endoscopically visible lesions. MAIN OUTCOME MEASUREMENTS: Complete resection of neoplastic lesion, lack of variceal bleeding. RESULTS: Four patients were treated with endoscopic mucosal resection a total of 5 times. Endoscopic mucosal resection was successfully performed without significant GI bleeding. LIMITATIONS: This preliminary case series describes feasibility of the procedure. Whether this can be generalized remains to be determined, although it may be an option in poor surgical candidates. CONCLUSIONS: Endoscopic mucosal resection appears to be relatively safe in selected patients with portal hypertension and Barrett's esophagus. Further studies are needed to confirm these findings.     

Chicken soup for teaching and learning ESD

Endoscopic submucosal dissection(ESD) is becoming a popular procedure for the diagnosis and treatment of superficial mucosal lesions,and has the advantage of en bloc resection which yields a higher complete resection and remission rate compared to endoscopic mucosal resection(EMR).However,the learning process of this advanced endoscopic procedure requires a lengthy training period and considerable experience to be proficient.A well framed training protocol which is safe,effective,easily reproducible and cos...