Clinical impact of endoscopic submucosal dissection for superficial adenocarcinoma located at the esophagogastric junction

BACKGROUND: Surgery is the standard treatment for neoplasms located at the esophagogastric junction (EGJ), and, recently, EMR, photodynamic therapy (PDT), or both have also been used for early stage neoplasms located at the EGJ. Endoscopic submucosal dissection (ESD) is a newly developed technique in the field of endoscopic treatments for GI neoplasms because of its high rate of en bloc resection. OBJECTIVE: We used ESD for superficial adenocarcinoma located at the EGJ and evaluated its clinical impact. PATIENTS: Twenty-five lesions of superficial adenocarcinomas located at the EGJ from 24 patients were treated with ESD between June 2001 and January 2006. An adenocarcinoma located at the EGJ was defined as a "junctional carcinoma (type II)" according to Siewert's classification. MAIN OUTCOME MEASUREMENT: Complications, en bloc resection rate, curative resection rate, local recurrence, and distant metastasis were evaluated. RESULTS: No complications except stenosis occurred. The en bloc resection rate was 100%. Seventeen lesions (72.0%) were judged as "curative resection" and showed no local or distant recurrence during a median follow-up period of 30.1 months. Seven lesions were diagnosed as "noncurative resection." Two patients underwent additional surgical resections. In 1 of 2 of the surgical resections, however, we could not identify a residual cancer. In 1 patient, who refused additional surgical resection, lung metastases were found after 3 years. LIMITATIONS: The limitation of the study was its retrospective design. CONCLUSIONS: After long-term follow-up, although surgery for a noncurative resection remains a standard treatment, ESD can be adequately adopted as an effective treatment for superficial adenocarcinomas at the EGJ.     

Case series of endoscopic balloon dilation to treat a stricture caused by circumferential resection of the gastric antrum by endoscopic submucosal dissection

BACKGROUND: Endoscopic submucosal dissection (ESD) plays an important role in the management of gastric neoplasms. There are few reports regarding stricture development caused by ESD of gastric neoplasms. OBJECTIVE: The present study aimed to determine the incidence of gastric stricture formation after ESD of gastric neoplasms and to report on the outcome and management of this complication: endoscopic intervention (ie, balloon dilation) versus surgery; the outcome of balloon dilation (success or failure/perforation). DESIGN: A case series from a retrospective review of gastric ESDs performed at Saga Medical School over a defined period of time. SETTING: Double-center territory, referral hospital. PATIENTS: An evaluation was performed in 532 patients with gastric mucosal tumors treated by ESD. A stricture was reported in 5 patients. All the 5 cases were located in the antrum. ESD that was performed in the cardia or the proximal stomach did not induce a stricture. RESULTS: Of the 5 cases of symptomatic gastric outlet obstruction, 1 patient required surgical intervention because of a near total gastric outlet obstruction not amenable to endoscopic intervention. The 4 patients underwent step-serial through-the-scope balloon dilations; in 2 patients, the procedure was successful, but in the other 2 patients, the procedure was complicated by a gastric perforation (50% incidence of perforation). LIMITATION: A retrospective study. CONCLUSIONS: Circumferential or subcircumferential resection by ESD in the antrum caused a stricture. Balloon dilation of the ESD gastric outlet obstruction might be a choice, but it is a risky treatment.     

食管胃结合部早期癌内镜黏膜下剥离术与外科手术的长期随访结果比较

目的评估内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)与外科切除治疗食管胃结合部(esophagogastric junction,EGJ)早期腺癌的远期疗效。方法2004年1月至2018年6月,山西省人民医院消化内镜中心和胃肠胰外科连续收治的EGJ早期腺癌病例纳入回顾性分析,术前评估符合ESD治疗绝对标准或扩大标准,且术后病理评估符合治愈性切除绝对标准或扩大标准的166例病例资料纳入数据分析,按治疗方法分成ESD组(n=77)和外科切除组(n=89),对比2组的近期结果(治愈性切除率、并发症)和远期结果(累积生存率)。结果ESD组中符合ESD治疗绝对标准者65例(84.4%)、符合扩大标准者12例(15.6%),外科切除组中符合ESD治疗绝对标准者60例(67.4%)、符合扩大标准者29例(32.6%),2组在患者ESD治疗标准的构成上差异有统计学意义(P=0.011);其他基线指标2组间比较差异均无统计学意义(P均>0.05)。ESD组整块切除率为98.7%(76/77)、完全切除率为94.8%(73/77)、治愈性切除率为93.5%(72/77),外科切除组治愈性切除率为100.0%(89/89),2组治愈性切除率比较差异无统计学意义(P=0.05)。ESD组有3例(3.9%)术中出血、1例(1.3%)术后早期出血和2例(2.6%)术中穿孔,外科切除组有1例(1.1%)术中出血、4例(4.5%)术后出血和2例(2.2%)术后吻合口微漏。2组均无术后1个月内死亡病例,亦无局部复发病例。ESD组随访时间72.5~105.7个月,中位时间89.3个月;外科治疗组随访时间69.6~101.0个月,中位时间82.3个月。2组随访期间均无肿瘤相关死亡病例和复发。ESD组与外科切除组的5年生存率分别为94.8%(73/77)和96.6%(86/89),2组累积生存率比较差异无统计学意义(P=0.648)。亚组分析显示,符合ESD绝对标准者,ESD治疗与外科切除治疗的累积生存率比较,差异无统计学意义(P=0.449);符合ESD扩大标准者,ESD治疗与外科切除治疗的累积生存率比较,差异亦无统计学意义(P=0.505)。结论对于符合ESD治疗绝对标准和扩大标准的EGJ早期腺癌,ESD治疗的远期肿瘤学结果与外科切除类似,可作为外科切除治疗的有效替代方式。     

Randomized controlled trial comparing submucosal endoscopy with mucosal resection and endoscopic submucosal dissection in the esophagus and stomach: Animal study

Background and Aim

In Western countries, endoscopic submucosal dissection (ESD) has not prevailed as a result of training problems and a target patient population. We have previously reported a hybrid ESD technique, submucosal endoscopy with mucosal resection (SEMR), in which the submucosal dissection is carried out chiefly by blunt balloon dissection. We have also reported successful application in the porcine colon. In the present study, we compared the safety and efficacy of SEMR with ESD in the porcine esophagus and stomach.

Methods

SEMR and ESD were carried out in eight domestic pigs under general anesthesia. Resection sites were marked by circumferential coagulation. After circumferential ESD knife mucosal incision, submucosal fluid cushion (SFC) was created. In the SEMR group, the balloon catheter was inserted deep into the SFC. The balloon was then inflated and pulled back toward the endoscope tip repeatedly, altering the direction, to disrupt the submucosa. Residual strands were cut with an IT‐knife. En bloc resection rates, procedure times, complications and dissection difficulty scales (DDS) were recorded prospectively. DDS were rated using a visual analog scale.

Results

Thirty‐two resections (8 SEMR/8 ESD in the esophagus; 8 SEMR/8 ESD in the stomach) were done with no major adverse events. There was no statistical difference between the two techniques in either location in the above categories measured.

Conclusions

SEMR and traditional ESD are comparable techniques in safety and effectiveness when carried out in the esophagus and stomach. SEMR may serve as a more appealing technical option for endoscopists who are unable to sustain a traditional ESD practice volume.     

Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos)

BACKGROUND: Endoscopic submucosal dissection (ESD) enables direct submucosal dissection so even large early stage GI tumors can be resected en bloc. Colorectal ESD is technically more difficult, however, and there is an increased risk of complications such as perforation and bleeding compared with gastric ESD. As a result, further refinements are required in this procedure. OBJECTIVE: Our purpose was to evaluate thin endoscope-assisted (TEA) ESD, a new traction system for improving submucosal cutting line visualization. DESIGN: Case series. SETTING: Okayama University Hospital. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of the TEA-ESD procedure. RESULTS: Three cases of large, flat, elevated colorectal tumors (laterally spreading tumors) in the rectum and rectosigmoid colon were safely and successfully removed en bloc without complications. Total procedure times were 3 hours, 40 minutes, and 30 minutes with resected specimens measuring 70 x 68 mm, 38 x 35 mm, and 30 x 20 mm, respectively. LIMITATIONS: TEA-ESD was performed in only the rectum and rectosigmoid colon. CONCLUSIONS: This limited case series demonstrated that large laterally spreading tumors in the rectum and rectosigmoid colon could be safely resected en bloc with TEA-ESD.