Do we have enough evidence for expanding the indications of ESD for EGC?

Endoscopic submucosal dissection(ESD) is the most advanced and representative technique in the field of therapeutic endoscopy and has been used for the treatment of gastrointestinal neoplasms,including early gastric cancer.The major difference and advantage of ESD compared to existing endoscopic resection techniques,such as endoscopic mucosal resection(EMR) and polypectomy,are the width and depth of the resection.Newly developed cutting devices,distal attachable endoscopic accessories,and an advanced electr...     

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR RECURRENT GASTRIC TUMORS

Endoscopic resection has been accepted as the standard treatment for intramucosal gastric tumors of differentiated type. However, the indication was limited to small tumors to achieve en bloc resection and prevent local recurrence in cases of conventional endoscopic mucosal resection (EMR) such as the strip biopsy and the cap technique. To avoid multi‐fragmental resection, we have developed endoscopic submucosal dissection (ESD) as a new endoscopic resection technique. ESD is a remarkable technique, because we make it possible to remove the lesions en bloc regardless of size, shape, coexisting ulcer, and location. However, it is difficult or impossible to resect recurrent tumors en bloc in conventional EMR owing to hard fibrosis, and some patients need laparotomy. Using ESD, we can dissect the submucosal layer as we directly look at the submucosa, and remove the lesion safely and reliably even in cases of hard fibrosis. The key to treatment of recurrent tumors in ESD are as follows: (i) using enough submucosal injection solution (we use a mixture of Glyceol and 1% 1900 kDa hyaluronic acid preparation); (ii) incising the mucosa without fibrosis; (iii) understanding characteristics of various cutting devices, and changing other devices in difficult situations. In these ways we can remove the majority of the recurrent tumors en bloc. Hence, we consider that ESD is a very effective treatment which achieves excellent en bloc and complete resection rates and enables patients with intramucosal gastric tumors to a recurrent‐free survival even in recurrent tumors.     

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in 2011, a Western perspective

Endoscopic mucosal resection (EMR) has become the standard of care for removal of large flat and sessile neoplastic lesions of the GI tract. Recently, endoscopic submucosal dissection (ESD) was introduced in Japan as an alternative technique, which allows en bloc resection of large lesions. The applications of EMR and ESD are expanding and many Western endoscopists are adopting these techniques. Paris classification and Kudo pit pattern classification allows prediction of the depth of invasion of early neoplastic lesions and thus, avoids resection of lesions invading the deep submucosa which have higher rates of lymphatic spread. ESD of early stomach cancer is the standard of care in Japan. Recent published reports from Western countries showed comparable results for ESD of early gastric cancers to those done in Japan. Recently, EMR combined with ablation has been used frequently in Western countries for treatment of high-grade dysplasia in early adenocarcinoma of the esophagus. Although ESD of early neoplastic lesions of the esophagus is technically difficult, few promising reports were published proving the feasibility of this technique in the West. ESD has been shown to achieve higher en bloc resection and lower rates of tumour recurrence in removal of lateral spreading colonic polyps. A hybrid technique of circumferential submucosal incision followed by en bloc EMR has been used for removal of large colonic lesions in some Western endoscopy centres. In Western countries, training for ESD is challenging given the lack of training in the relatively easier early gastric cancer lesions. Animal model training combined with observing experts in ESD could be an alternative for Western endoscopists. Inspite of obstacles, ESD applications are continuing to grow in Western countries.     

Investigation of ulcer healing after esophageal EMR/ESD

Background  

Endoscopic mucosal resection (EMR) for early esophageal cancer has become popular. Recently, endoscopic submucosal dissection (ESD) has been used to excise widespread lesions en bloc. However, the time required for the ulcer to heal has not been clarified. Therefore, we investigated the healing time of ulcers that were formed after EMR/ESD.     

Endoscopic submucosal dissection compared to endoscopic mucosal resection for early Barrett esophagus neoplasia

Endoscopic resection has become an invaluable diagnostic and therapeutic tool in the evaluation and management of early Barrett esophagus (BE) neoplasia. While endoscopic mucosal resection (EMR) is the current standard of care for the resection of nodular early BE neoplasia, endoscopic submucosal dissection (ESD) has been recently introduced as part of the armamentarium in the treatment of these lesions. The potential advantages of ESD compared to EMR include higher en-bloc and R0 resection rates, decreased local recurrence, and the procurement of large en-bloc specimens that may facilitate pathologic staging. On the other hand, EMR is less time-consuming and has been traditionally associated with a lower incidence of serious adverse events when compared to ESD. At present, the choice of the endoscopic resection technique hinges on operator’s preferences, patient and lesions characteristics and available local expertise. Future high-quality studies comparing clinical outcomes between ESD and EMR are needed to better define their roles in the management of early BE neoplasia.     

Endoscopic mucosal resection and endoscopic submucosal dissection for early gastric cancer: Current and original devices

Compared with endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) is easier to perform and requires less time for treatment. However, EMR has been replaced by ESD, because achieving en bloc resection of specimens > 20 mm in diameter is difficult with EMR. The technique of ESD was introduced to resect large specimens of early gastric cancer in a single piece. ESD can provide precise histological diagnosis and can also reduce the rate of recurrence, but has a high level of technical difficulty, and is consequently associated with a high rate of complications, a need for advanced endoscopic techniques, and a lengthy procedure time. To overcome disadvantages in both EMR and ESD, various advances have been made in submucosal injections, knives, other accessories, and in electrocoagulation systems.     

重视并开展内镜黏膜下剥离术的规范化操作

内镜切除术治疗胃肠道早期肿瘤正日益被接受并开展应用,包括传统的内镜黏膜切除术（EMR）和近年开展的内镜黏膜下剥离术（ESD）。EMR对于15mm以上的病灶较难做到一次切除,而整块切除标本对病理学评估至关重要,ESD正是应这一要求开展起来的新技术。对局限于黏膜层的病变,ESD并不受其大小的限制,对部分早期胃肠道肿瘤,其可取代传统的手术治疗,但ESD需要相当高的内镜操作技术,术前需要多种方法对病灶进行谨慎、全面的评估,包括范围、浸润深度等,术中、术后还可能出现出血、穿孔等严重的并发症,其发生率远高于EMR。ESD的指征、操作技巧、病理评估等方面还需要不断完善。由于ESD在早期胃肠道肿瘤的治疗上具有很多优点,值得有条件医院的内镜医师予以重视并开展这一技术。     

Endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms

Endoscopic resection is an effective treatment for noninvasive esophageal squamous cell neoplasms(ESCNs).Endoscopic mucosal resection(EMR)has been developed for small localized ESCNs as an alternative to surgical therapy because it shows similar effectiveness and is less invasive than esophagectomy.However,EMR is limited in resection size and therefore piecemeal resection is performed for large lesions,resulting in an imprecise histological evaluation and a high frequency of local recurrence.Endoscopic submucosal dissection(ESD)has been developed in Japan as one of the standard endoscopic resection techniques for ESCNs.ESD enables esophageal lesions,regardless of their size,to be removed en bloc and thus has a lower local recurrence rate than EMR.The development of new devices and the establishment of optimal strategies for esophageal ESD have resulted in fewer complications such as perforation than expected.However,esophageal stricture after ESD may occur when the resected area is larger than three-quarters of the esophageal lumen or particularly when it encompasses the entire circumference;such a stricture requires multiple sessions of endoscopic balloon dilatation.Recently,oral prednisolone has been reported to be useful in preventing post-ESD stricture.In addition,a combination of chemoradiotherapy(CRT)and ESD might be an alternative therapy for submucosal esophageal cancer that has a risk of lymph node metastasis because esophagectomy is extremely invasive;CRT has a higher local recurrence rate than esophagectomy but is less invasive.ESD is likely to play a central role in the treatment of superficial esophageal squamous cell neoplasms in the future.     

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...     

内镜智能分光比色技术定位下EMR及ESD治疗大肠侧向发育型肿瘤的疗效比较

[目的]比较内镜智能分光比色技术(FICE)定位下内镜下黏膜切除术(endoscopic mucosal resection,EMR)及内镜黏膜下剥离术(endoscopic submucasal dissection,ESD)治疗大肠侧向发育型肿瘤(LST)的效果。[方法]63例LST患者在FICE定位下分别行EMR(38例)及ESD(25例)治疗,对比分析EMR和ESD两种方法的切除效果、手术时间及并发症。[结果]对于最大径≤20mm的肿瘤,EMR和ESD两种方法均能整块切除,且无肿瘤残留(P0.05);对于最大径20mm的肿瘤,ESD能整块切除,EMR需分次切除(P0.05),且ESD术后肿瘤残留明显少于EMR(P0.05)。ESD手术时间明显长于EMR(P0.05),但术后出血率和穿孔率,两者比较差异无统计学意义(P0.05)。[结论]ESD治疗LST安全有效,而EMR操作简便,用时较短,对于≤20mm的LST仍然是一种较好的选择。     

Endoscopic submucosal dissection for gastrointestinal neoplasms

Endoscopic submucosal dissection （ESD） is an advanced technique of therapeutic endoscopy for superficial gastrointestinal neoplasms. Three steps characterize it：injecting fluid into the submucosa to elevate the lesion, cutting the surrounding mucosa of the lesion, and dissecting the submucosa beneath the lesion. The ESD technique has rapidly permeated in Japan for treatment of early gastric cancer, due to its excellent results of en- bloc resection compared to endoscopic mucosal resection （EMR）. Although there is still room for improvement to lessen its technical difficulty, ESD has recently been applied to esophageal and colorectal neoplasms. Favorable short-term results have been reported, but the application of ESD should be well considered by three aspects：（1） the possibility of nodal metastases of the lesion, （2） technical difficulty such as location, ulceration and operator＇s skill, and （3） organ characteristics.     

Endoscopic submucosal dissection of early gastric cancer

The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.     

Endoscopic submucosal dissection using flexknife

Although the standard treatment for early-stage gastrointestinal tumors is still surgical resection, endoscopic resection has been accepted for some of these lesions, especially in Japan. However, the indication was limited until recently to achieve en bloc resection and prevent local recurrence. To overcome the disadvantage of endoscopic resection with conventional endoscopic mucosal resection (EMR), several investigators, including us, have developed a new endoscopic resection technique: endoscopic submucosal dissection (ESD). ESD is a remarkable technique that enables to remove the lesions en bloc regardless of size, shape, coexisting ulcer, and location. Nowadays, several knives are available for ESD, such as the needle knife, insulation-tipped (IT) knife, Hookknife, triangle-tipped (TT) knife, and Flexknife. Each of them has some merits and demerits, and the ways to use the knives are different. We summarize here how to use the Flexknife, which we made ourselves in cooperation with the Olympus Company, and how we use the technique in our hospital.     

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.     

Selection of EMR and ESD for Laterally Spreading Lesions of the Colon

Introduction

Colonic laterally spreading lesions (LSL) are increasingly managed using endoscopic methods that comprise two main techniques: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

Purpose of Review

In this review, we aimed to review the most recent literature on selection of the best endoscopic technique in the management of colonic LSL.

Recent Findings

EMR and ESD are complimentary techniques in the management of patients with colonic LSL.

Summary

EMR is safe and effective in most patients with LSL, except for cancers with submucosal invasion in whom R0 resection is favored.

     

ESD在治疗早期胃癌及癌前病变中的应用

内镜黏膜下剥离术（ESD）是一种安全有效的内镜下微创治疗新技术。ESD技术具有可完整切除较大病灶、切除溃疡型病灶、提供完整病理诊断材料及预防复发等优点,为早期胃癌及胃癌前病变的诊疗开辟了新的途径。本文通过详细介绍ESD的发展、ESD的适应证、操作中所需的特殊器械及其并发症的处理,结合大量临床资料,明确ESD技术在早期胃癌和癌前病变中的应用价值。     

Endoscopic submucosal dissection for early gastric cancers: experience from a new endoscopic center in Taiwan

GOAL: To evaluate the efficacy of endoscopic submucosal dissection (ESD) for early gastric cancers (EGCs) at a new endoscopic center. BACKGROUND: ESD is a novel technique that can facilitate en-bloc resection of EGCs, but seldom reported outside Japan. STUDY: A total of 25 consecutive patients (25 lesions) underwent ESD from June 2004 to March 2006. Patients were divided into 2 groups: group A underwent ESD from June 2004 to May 2005 (introduction stage) and group B from June 2005 to March 2006. The following data were obtained: tumor size, tumor location, operative time, and major complication. RESULTS: The complete resection was achieved in 20 lesions (success rate 80%). Four out of 10 lesions from group A were removed by conventional endoscopic mucosal resection (EMR) piecemeally after ESD failure. Conversely, 14 patients from group B (n=15) were resected by ESD en-bloc (success rate 93.3%). One patient with microscopic residual tumor after ESD was further treated by surgical resection. The time required for resection was significantly longer in group A when compared with group B (130.5 min vs. 81.5 min, P<0.05). Postoperative complication rate between the 2 groups were similar. One patient with piecemeal EMR recurred in follow-up, and was further treated successfully by EMR. CONCLUSIONS: ESD is an ideal method for EGC treatment, but it may result in a risk of complication. The complete resection rate can be improved by endoscopist's experience. Sophisticated endoscopic hemostasis and clipping skills are essential prior ESD procedures. Conventional EMR techniques are also obligatory during the beginning period.     

内镜治疗早期肠道肿瘤相关问题探讨

内镜黏膜下剥离术(ESD)与内镜黏膜切除术(EMR)是消化道内镜手术中的两种重要手术方式,目前基于两者又出现了改良的新术式：ESD-S(ESD with snare,ESD联合圈套器法)与EMR-P术(EMR with precutting,预环切EMR法)。这四种手术方式在治疗结直肠肿瘤中具有各自不同的优缺点,如较高的完全切除率,较低的并发症风险等。综合近几年国际发表的临床试验,笔者认为：对于直径小于20 mm的结直肠肿瘤,可根据肿瘤的情况,选择ESD术、ESD-S术,EMR-P术或者EMR术。对于直径大于20 mm的肿瘤,ESD术与ESD-S术由于其较低的复发率与较高的完全切除率,可以作为处理此类肿瘤的首选。如上述两种术式风险较高,可以采用EMR-P进行处理。EMR术由于完全切除率较低,复发率偏高,而大于20 mm肿瘤恶变风险较高,不适合用于这类肿瘤的切除。     

Endoscopic removal of gastric ectopic pancreas: An initial experience with endoscopic submucosal dissection

AIM:To evaluate the therapeutic usefulness and safety of endoscopic resection in patients with gastric ectopic pancreas.METHODS:A total of eight patients with ectopic pancreas were included.All of them underwent endoscopic ultrasonography before endoscopic resection.Endo-scopic resection was performed by two methods:endo-scopic mucosal resection(EMR)by the injection-and-cut technique or endoscopic mucosal dissection(ESD).RESULTS:We planned to perform EMR in all eight cases but EMR was successful in only four cases.In the other four cases,saline spread into surrounding normal tissues and the lesions becameattened,which made it impossible to remove them by EMR.Inthose four cases,we performed ESD and removed the lesions without any complications.CONCLUSION:If conventional EMR is difficult to remove gastric ectopic pancreas,ESD is a feasible alternative method for successful removal.     

Matched case-control study comparing endoscopic submucosal dissection and endoscopic mucosal resection for colorectal tumors

Background and Aim: For large colorectal tumors, the en bloc resection rate achieved by endoscopic mucosal resection (EMR) is insufficient, and this leads to a high rate of local recurrence. As endoscopic submucosal dissection (ESD) has been reported to achieve a higher rate of en bloc resection and a lower rate of local recurrence in the short‐term, it is expected to overcome the limitations of EMR. We conducted a matched case‐control study between ESD and EMR to clarify the effectiveness of ESD for colorectal tumors. Methods: Between April 2005 and February 2009, a total of 28 colorectal tumors in 28 patients were resected by ESD and were followed up by colonoscopy at least once. As a control group, 56 EMR cases from our prospectively completed database were matched. En bloc resection, complication and recurrence rates were compared between the two groups. Results: The mean sizes of the lesions were 27.1 mm in the ESD group and 25.0 mm in the EMR group. The en bloc resection rate was significantly higher in the ESD group (92.9% vs 37.5% with ESD vs EMR), and the rate of perforation was also significantly higher (10.7% vs 0%). All cases of perforation were managed conservatively. No recurrence was observed in the ESD group, whereas local recurrences were detected in 12 EMR cases (21.4%). Eleven of the 12 recurrences (91.7%) were managed endoscopically, and one required surgical resection. Conclusions: Endoscopic submucosal dissection is a promising technique for the treatment of colorectal tumors, giving an excellent outcome in comparison with EMR.