Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. MATERIALS AND METHODS: All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. RESULTS: In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. CONCLUSIONS: The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.     

Squamous reepithelialization after circumferential endoscopic mucosal resection of superficial carcinoma arising in Barrett's esophagus

Recent reports on the results of endoscopic ablation of Barrett's mucosa have been promising, particularly when total mucosal ablation is coupled with aggressive acid-suppression treatment using high-dose proton-pump inhibitor therapy. There is also a considerable literature on reepithelialization after ablative treatments in Barrett's esophagus. This report describes a case of multifocal superficial adenocarcinoma arising in Barrett's mucosa that was successfully treated with total circumferential endoscopic mucosal resection, with a subsequent follow-up of more than 2 years. This is the first report describing the process of squamous reepithelialization after endoscopic mucosal resection in Barrett's esophagus.     

Curative treatment for high-grade intraepithelial neoplasia in Barrett's esophagus

BACKGROUND AND STUDY AIMS: The incidence of premalignant and malignant lesions in specialized intestinal metaplasia of the esophagus has increased dramatically in the industrialized world in recent years. This report evaluates the efficacy and safety of local endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) in Barrett's esophagus. PATIENTS AND METHODS: Over a 5-year period between October 1996 and September 2001, a total of 379 patients were referred with a suspicion of early Barrett's cancer. In a prospective study, 44 patients with HGIN in Barrett's esophagus were selected for local endoscopic treatment. Endoscopic resection was carried out in 14 patients in whom the HGIN was re-detectable, and 27 patients in whom the HGIN was not re-detectable underwent photodynamic therapy (PDT). Endoscopic resection and PDT were combined in three patients. RESULTS: Complete remission was achieved in 43 of the 44 patients (97.7 %). No major complications occurred. A mean of 1 session was needed to achieve complete local remission. During a mean follow-up period of 36 months (range 7 - 61 months), recurrent or metachronous lesions were observed in six patients (17.1 %), all of whom received a second successful endoscopic treatment. CONCLUSIONS: Endoscopic therapy is a safe alternative treatment regimen for HGIN in Barrett's esophagus, providing a middle way between the widely promulgated options of a "watch-and-wait" policy and radical esophagectomy.     

Endoscopic mucosal resection in the esophagus with a new rigid device: an animal study

BACKGROUND AND STUDY AIMS:: There is a growing trend toward the use of minimally invasive endoscopic methods to treat early esophageal cancers. Although there is continuing controversy regarding the management of Barrett's esophagus and the value of surveillance programs continues to be debated, the ultimate goal is to eradicate all of the foci of intestinal metaplasia and hence the risk of developing an adenocarcinoma. A number of ablative techniques have so far been applied, but none has yet been shown to be superior and entirely satisfactory. The present study evaluates the feasibility, efficacy, and safety of a promising new method of endoscopic mucosal resection (EMR) in a sheep model, based on the use of a modified rigid esophagoscope. MATERIALS AND METHODS: The resectoscope consists of a rigid esophagoscope with a distal transparent window through which the mucosa and part of the submucosa are sucked in and then resected with a wire loop. The sheep model was chosen because of its similarities to human anatomy with regard to the thickness and histological structure of the esophagus. Fifty-five separate hemicircumferential resections and 11 circumferential resections were carried out in 21 and 11 animals, respectively. Mitomycin C, an agent inhibiting fibroblast proliferation, was administered at different time intervals after eight circumferential resections to prevent the development of esophageal strictures. Results : All of the specimens of hemicircumferential resections were obtained as single distinct pieces and were easily examined histologically. The surface of the specimen correlated with the size of the window and ranged from 6 to 12 cm (2). In circumferential resections, the specimens were obtained in two pieces. An accurate resection depth through the submucosa was achieved in 58 of 65 resected specimens. No complications occurred after hemicircumferential resections. Complications after circumferential resections (stenosis or perforation, or both) were minimized after appropriate timing of mitomycin C administration. CONCLUSIONS: This EMR method offers a promising approach in comparison with other options currently available. It appears to be superior in terms of the size of the resected specimen, the precision and regularity of the resection depth, and the accuracy of histological diagnosis with safety margins. Hemicircumferential EMRs have been shown to be safe in the sheep model. This new technique warrants further animal studies before being used for circumferential EMR in humans.     

Endoscopic circumferential esophageal mucosectomy in a porcine model: an assessment of technical feasibility, safety, and outcome

BACKGROUND AND STUDY AIMS: Endoscopic mucosectomy has been performed for early cancers and dysplastic lesions < or = 2 cm in diameter. The feasibility and safety of mucosectomy for circumferential lesions of the esophagus is uncertain. The aim of this study was to determine the technical feasibility, as well as the short and long-term complication rates, with circumferential endoscopic mucosectomy of the distal esophagus in the pig. MATERIALS AND METHODS: Circumferential endoscopic mucosectomy of the distal 3 cm of the esophagus was performed in four pigs, using a cap mucosectomy device. The animals were sacrificed after 30, 50, 70, and 90 days to assess mucosal regeneration and stricture formation. RESULTS: The procedure time for circumferential endoscopic mucosectomy was 15-30 min. Circumferential endoscopic mucosectomy was technically feasible and without short-term complications. Videotapes of all resections were reviewed to ensure that complete removal of the mucosa was achieved. All mucosectomy specimens underwent histological evaluation. The specimens included the mucosa alone in three of the pigs. Some of the specimens in the fourth pig included a superficial layer of muscularis propria. This pig failed to thrive. Macroscopic examination of the dissected esophageal specimens from the healthy pigs revealed a well-healed, normal-appearing esophagus, whereas a stenosis of 4 x 10 mm was observed in the distal esophagus of the pig that failed to thrive. CONCLUSIONS: Circumferential endoscopic mucosectomy of the porcine distal esophagus is feasible and safe. An adequate submucosal saline cushion is essential to prevent stenosis due to deep injury.     

Endoscopic mucosal resection scissors for the treatment of early gastric cancer

Endoscopic mucosal resection (EMR) is currently a common treatment for superficial gastrointestinal tumors. We have developed new EMR scissors for superficial lesions in the esophagus and stomach. These scissors have stainless steel blades with an electrocoagulation device for hemostasis. We report a case in which superficial gastric cancer was treated by means of the EMR scissors. The lesion was removed using the scissors and no major complication was encountered. EMR scissors can be used for endoscopic resection of superficial lesions of the esophagus and stomach.     

Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastrointestinal cancers has been shown to be effective in treating mucosal malignancies, but en bloc resection (where the entire tumor is removed in one piece) is often not achieved using conventional cap EMR. Other techniques, developed in Japan, include the application of different types of knife such as the insulated-tip instrument. We report our preliminary experience of the use of this knife, in conjunction with other techniques, in attempting en bloc resection of early mucosal cancers and adenomas and in the removal of submucosal tumors (SMTs) of the upper gastrointestinal tract. PATIENTS AND METHODS: A total of 37 patients (26 men, 11 women, age range 53 - 86) were included in the study; 23 patients had 24 mucosal lesions amenable to EMR, and 14 patients had SMTs shown on endosonography to spare the muscularis propria. Lesions were located in the esophagus (n = 13), the stomach (n = 24), and the duodenum (n = 1); 40 % of the mucosal lesions were 20 mm or larger (mean size 18mm), whereas the mean size of the submucosal lesions was 23 mm. After submucosal saline injection, circumcision and dissection of the mucosal lesions was attempted with the aim of achieving en bloc resection. For SMTs, cap mucosectomy of the overlying mucosa was done first, and the tumors were then freed using saline injection, and finally resected using snare polypectomy. RESULTS: The strict aim of the study, i. e. complete tumor removal in a single piece, was achieved in only 25 % of the mucosal lesions (some failures were due to unrecognized submucosal infiltration) and 36 % of the SMTs. When a more liberal definition of success was assumed, this rate increased to 65 % for mucosal lesions (piecemeal, no tumor found at surgery or follow-up endoscopy with biopsy) and 79 % for SMTs (piecemeal). No severe complications necessitating surgery or leading to major morbidity occurred. However, clinically significant complications were found in six patients (minor perforation managed conservatively (n = 1), severe pain without perforation (n = 1), bleeding requiring reintervention (n = 3), and aspiration (n = 1)). CONCLUSIONS: Although we are convinced that methods of achieving en bloc resection of mucosal cancers and SMTs must be pursued, the insulated-tip knife in conjunction with conventional endoscopes still has limitations. Innovative endoscope design (double-channel scopes) as well as the development of new accessories will help to overcome the current limitations and further promote endoscopic tumor resection.     

Intraepithelial high-grade neoplasia and early adenocarcinoma in short-segment Barrett's esophagus (SSBE): curative treatment using local endoscopic treatment techniques

BACKGROUND AND STUDY AIMS: In recent years, short-segment Barrett's esophagus (SSBE) has attracted increasing attention in the context of reflux disease. However, there is continuing controversy regarding its potential for malignant transformation. PATIENTS AND METHODS: Between October 1996 and September 1999, 50/115 patients (43 %) with intraepithelial high-grade neoplasia or early Barrett's adenocarcinoma, who underwent local endoscopic treatment, had developed a malignant lesion in an (SSBE). In the framework of a prospective observational study, 28 patients were treated with endoscopic mucosal resection (EMR), 13 with photodynamic therapy, and three with argon plasma coagulation; six patients received combinations of these treatments. RESULTS: Complete local remission was achieved in 48/49 patients (98 %). One patient switched to surgery after the first EMR, because there was submucosal tumor infiltration, and in one patient out of 50 local endoscopic treatment failed. A mean of 1.7 +/- 1.4 treatment sessions was required for local endoscopic treatment. The method-associated mortality was 0 %. The rate of relevant complications (stenosis, bleeding) was 6 % (3/50 patients). No cases of severe hemorrhage (Hb fall >2 g/dl) or perforation occurred. During a mean follow-up period of 34 +/- 10 months, metachronous intraepithelial high-grade neoplasms or early adenocarcinomas were seen in 11/48 patients (23 %), who received further successful endoscopic treatment. Four patients died during the follow-up period, but in only one patient was this due to his Barrett's adenocarcinoma (this was the patient who underwent esophageal resection). CONCLUSIONS: The malignant potential of short-segment Barrett's esophagus must not be underestimated. Organ-preserving local endoscopic treatment shows good acute-phase and long-term results. Local endoscopic treatment represents an alternative to esophageal resection in the case of intraepithelial high-grade neoplasia and selected early adenocarcinomas in Barrett's esophagus.     

Endoscopic ablation of Barrett's neoplasia with a new focal radiofrequency device: initial experience with the Halo60

Radiofrequency ablation (RFA) is an accepted treatment for the eradication of dysplastic Barrett's esophagus (DBE) and residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma. Circumferential balloon-based and focal catheter-based RFA devices are currently used (the Halo360 and Halo90). However, a new smaller focal ablation device (the Halo60) has been developed, which may be of benefit in patients with short tongues of Barrett's neoplasia, small residual islands, difficult anatomy, or strictures. We report the first use of this device in 17 patients with either DBE or residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma.     

Recurrence after endoscopic mucosal resection for superficial esophageal cancer

BACKGROUND AND STUDY AIMS: We present the results of endoscopic mucosal resection (EMR) for superficial esophageal cancer in patients treated at the National Cancer Center Hospital East since March 1993, and discuss the factors involved in local recurrence. PATIENTS AND METHODS: The study consisted of 51 patients with a total of 57 superficial esophageal cancers which were treated by EMR at the National Cancer Center Hospital East between March 1993 and March 1998. EMR was performed with a two-channel fiberscope or with the assistance of the endoscopic esophageal mucosal resection tube. Follow-up examinations by means of endoscopy with iodine staining and biopsy were repeated every 3-6 months. RESULTS: A total of 19 patients had double cancers; 12 had head and neck cancers (HNC), six had stomach cancers, and one had lung cancer. The patients with HNC tended to have multiple iodine-unstained areas, and multiple cancers in the esophagus. Local recurrence was detected in two out of five patients (40%) with multiple esophageal cancers, and in two out of 46 patients (4%) with solitary cancer (P=0.0433). There was no difference in the rate of local recurrence between patients with HNC and those without HNC. Three out of four patients with recurrent cancers were given additional treatment, EMR for two and radiotherapy alone for one; no further recurrence occurred except in the patient who underwent radiotherapy alone. CONCLUSIONS: Multiplicity of cancer is a risk factor for local recurrence. Appropriate additional treatment should be indicated for recurrent lesions.     

内镜下黏膜切除术在消化道肿瘤中的应用

目的探讨内镜下黏膜切除术（EMR）在消化道肿瘤治疗中的价值。方法胃镜检查发现病灶后，利用超声内镜确定病变范围及浸润层次，对病灶位于黏膜及黏膜下层的消化道早期癌、癌前期病变、黏膜下肿瘤及宽基息肉的患者行EMR治疗。结果20例早期癌及中、重度异型增生者行EMR治疗，随访1-37个月，无1例复发及癌变，其中2例自行追加外科手术，术后病理均阴性。消化道黏膜下良性肿瘤8例，随访1-37个月，无1例复发。宽蒂息肉7例随访1-41个月，原部位无复发。术中并发出血2例、术后出血1例，均在内镜下或内科保守治疗止血成功。结论采用内镜下黏膜切除术治疗消化道早期癌、癌前期病变、黏膜下肿瘤及宽基息肉等，是一种可选择的、安全、有效的治疗方法，尤其适用高龄、合并有严重疾病及多次手术后不能再次外科手术的患者。     

Endoscopic therapy for Barrett's esophagus

There are many foreign reports about the endoscopic ablation therapy for Barrett's esophagus. Endoscopic ablation therapy include thermal therapy (electrocoagulation, laser etc.), photodynamic therapy or endoscopic resection and so on. Ablation of Barrett's esophagus by these therapy in combination with adequate acid suppression lead to mucosal replacement by squamous epithelium. But the true value of these endoscopic therapy has not been fully investigated. Further studies are required.     

Head and neck cancer arising after endoscopic mucosal resection for squamous cell carcinoma of the esophagus

BACKGROUND AND STUDY AIMS: It is well known that patients with head and neck cancer often have synchronous or metachronous squamous cell carcinoma of the esophagus. However, the prevalence of subsequent head and neck cancer in patients with early-stage esophageal cancer is still unknown. The aims of this study were to analyze the frequency of metachronous head and neck cancer after endoscopic mucosal resection (EMR) for esophageal cancer and to investigate whether minute iodine-unstained areas, often associated with squamous cell carcinomas, would be an index for metachronous head and neck cancer. PATIENTS AND METHODS: 99 patients with esophageal squamous cell carcinoma who underwent EMR were studied. Based on the iodine-staining pattern at initial EMR, they were categorized into those with uniform (group U) and scattered (group S) types of background mucosa. Patients were monitored endoscopically and otolaryngologically (group U, median 46 months, range 12-83 months; group S, median 44 months, range 13-80 months). RESULTS: In total, 5/99 patients (5.1 %) were found to have metachronous head and neck cancer during the follow-up, including 4/20 patients (20 %) in group S. In three cases laryngeal or hypopharyngeal cancer was found by endoscopic examination. The cumulative proportion of metachronous head and neck cancer-free subjects was significantly lower in group S than group U (P = 0.0007). CONCLUSIONS: Among patients who undergo EMR for esophageal carcinoma, those with scattered-type iodine staining of the background mucosa have an increased risk of metachronous head and neck cancer, and should therefore be closely observed. Careful endoscopic observation led to early detection of laryngeal and hypopharyngeal cancer.     

Risk factors for local recurrence of superficial esophageal cancer after treatment by endoscopic mucosal resection

BACKGROUND AND STUDY AIM: The aim of this study was to elucidate the risk factors for local recurrence after endoscopic mucosal resection (EMR) treatment for superficial esophageal cancer (SEC). PATIENTS AND METHODS: We performed a retrospective analysis of the clinical course of 62 patients with 64 SECs that were treated by EMR between 1993 and 2004. Follow-up examinations by chromoscopy with iodine solution and biopsy were performed 3 months, 6 months, 12 months, and then annually after EMR. Local recurrence was defined as a histologically confirmed finding of cancer cells at the site of the preceding EMR. The contributions of lesion-related and procedure-related factors to local recurrence were analyzed retrospectively. RESULTS: Local recurrence was detected in 14/64 SECs 3-36 months after EMR. Of the lesion-related factors we assessed, local recurrence was found to be more frequent in SECs with a larger diameter (P = 0.01), larger circumferential spread (P = 0.04), or deeper invasion (P = 0.04), although the last two factors failed to demonstrate statistical significance after correction for multiple testing. Piecemeal resection did not increase the risk of local recurrence (P = 0.11), but the need for adjunctive coagulation therapy was found to increase the risk of local recurrence (P = 0.06). CONCLUSIONS: Larger SECs are associated with a higher risk of local recurrence after EMR. In patients with residual lesions, coagulation therapy does not seem to be adequate as additional endoscopic treatment.     

Selective binding of sucralfate to endoscopic mucosal resection-induced gastric ulcer: evaluation of aluminium adherence

We evaluated the effect of sucralfate in patients with early gastric cancer in endoscopic mucosal resection (EMR)-induced gastric ulcers, and in rats with acetic acid-induced ulcers, by measuring concentrations of aluminium adhering to mucosal lesions. Twenty-two patients who underwent EMR received sucralfate with or without ranitidine and were examined endoscopically after 1 week, 2 weeks and 3 weeks. Gastric juice pH and concentration of aluminium in samples of ulcerated and normal mucosa were measured at various time-points. Good ulcer healing was observed in all patients. Significantly higher concentrations of aluminium were found in ulcerated tissue compared with normal mucosa. This selective binding of sucralfate was even found 12 h after drug administration and was confirmed in acetic acid-induced ulcers in 40 rats. Neutral rather than acid gastric juice was observed up to 12 h after the administration of sucralfate alone. These results suggest that sucralfate with or without ranitidine may contribute to the healing of EMR-induced ulcers by selectively binding to lesions.     

Endoscopic mucosal resection (EMR): results and prognostic factors in 21 patients

BACKGROUND AND STUDY AIMS: The aim of this study was to evaluate the efficacy of endoscopic mucosectomy (EM), and to present our experience with the endoscopic removal of superficial tumors of the gastrointestinal tract. PATIENTS AND METHODS: A total of 21 patients were included in the study (16 men, 5 women), between September 1995 and May 1997. In 16 cases the site of the lesions was an esophageal carcinoma, in two cases a gastric carcinoma, and in three cases a sessile polyp of the duodenum with severe dysplasia. Surgery was not recommended for the patients with esophageal or gastric tumors (on account of cardiac disease, cirrhosis or poor health). All patients underwent an endoscopic ultrasound (EUS) examination. The lesions were classified as usT1N0 in 20 cases, and usT0N0 in one case, according to the pretreatment EUS findings. We used the technique of polypectomy after submucosal injection of 10-15 ml of saline serum. RESULTS: Complications were encountered in 2/21 patients (9.5 %). Bleeding occurred in one case, but hemostasis was achieved endoscopically. In the other case, the patient presented with a thoracic pain and was treated by morphine injection. Endoscopic resection was considered to be complete in 19/21 patients (90.4%). In the other two cases, both involving esophageal tumors, histologic examination indicated only a partial tumor removal. However, these two patients had survived with negative EUS and endoscopic biopsy findings at 18 and 22 months later, respectively. None of the patients whose resections were considered complete presented with local recurrence, but three patients developed another superficial esophageal cancer, which was also treated by endoscopic mucosal resection (EMR). The mean follow-up was 20 months. CONCLUSIONS: EMR is a safe and efficient treatment of early gastrointestinal tumors. The development of high-frequency EUS probes may further improve the results of this technique in the future.     

Characteristics of metachronous multiple early gastric cancers after endoscopic mucosal resection

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastric cancer is a minimally invasive procedure. The incidence and characteristics of metachronous multiple gastric cancers were investigated in a retrospective study in patients with early gastric cancer after EMR treatment. PATIENTS AND METHODS: A total of 143 patients with early gastric cancer who had undergone EMR treatment were periodically followed up with endoscopic examinations for 24 months or longer. RESULTS: The median period of endoscopic follow-up was 57 months (range 24 - 157 months). None of the patients died of gastric cancer, and there were no treatment-related deaths. Five patients died of other diseases. Of 20 patients (14 %) with metachronous multiple gastric cancers, 15 were treated by EMR. One patient with differentiated submucosal cancer and four with undifferentiated cancers underwent surgery. Sixteen patients (11 %) had synchronous multiple early gastric cancer lesions within 1 year of the initial EMR. About half of the multiple lesions were located in the same third of the stomach as the primary lesion, and most lesions were similar in macroscopic type to the primary lesions. Most multiple lesions were of the differentiated type. CONCLUSIONS: Annual endoscopic examinations can preserve the whole stomach in most patients with early gastric cancer after successful EMR.     

Curative endoscopic therapy in patients with early esophageal squamous-cell carcinoma or high-grade intraepithelial neoplasia

BACKGROUND AND STUDY AIMS: Endoscopic resection of esophageal squamous-cell neoplasia with curative intent is considered to be a safe and effective alternative treatment to radical surgery in cases where the neoplasia is intraepithelial or limited to the mucosal layer. These patients are at risk for recurrent malignancy in the preserved esophagus, however. We conducted a prospective study to evaluate the efficacy and safety of endoscopic resection and to analyze variables associated with recurrence in patients with mucosal or intraepithelial squamous-cell neoplasia. PATIENTS AND METHODS: Between December 1997 and September 2005, 65 patients (mean age +/- standard deviation [SD] 62.9 +/- 9.5 years), 12 with high-grade intraepithelial neoplasia (HGIN) and 53 with mucosal squamous-cell cancer, were included in our study and were treated using endoscopic resection. Details of patient and tumor characteristics were documented prospectively. All patients were included in a staging protocol including high-resolution endoscopy with Lugol staining, endoscopic ultrasound, computed tomography, and abdominal ultrasound. Endoscopic resection was performed using a ligation technique. The data acquired were subjected to univariate and multivariate analysis. RESULTS: A total of 179 resections were performed (mean number of resections +/- SD per patient, 2.8 +/- 1.8): 11/12 patients with HGIN (91.7%), and 51/53 patients with mucosal cancer (96.2%) achieved a complete response during a mean follow-up period of 39.3 +/- 22.8 months; three patients were still under therapy at the end of the study period. Recurrence of malignancy after achieving a complete response was observed in 16 patients (26%), but these patients all achieved another complete response after further endoscopic treatment. Independent risk factors for recurrence was multifocal carcinoma (RR 4.1, P = 0.018). Tumor-related deaths occurred in two patients (3%), and eight patients died as a result of co-morbidity. Complications were seen in 15/65 patients (23%, all esophageal stenoses). The 7 year survival rate calculated for all groups was 77%. CONCLUSIONS: According to the results of long-term follow-up in this study, endosocopic resection appears to be an effective and safe method of curative treatment in patients with HGIN and mucosal squamous-cell carcinomas of the esophagus. Multifocal carcinoma and T1m1 tumors seem to be highly associated with recurrence.     

Mucosectomy for high-grade dysplasia in Barrett's esophagus.

Reports on the natural history of high-grade dysplasia (HGD) are sometimes contradictory, but suggest that 10-30% of patients with HGD in Barrett's esophagus (BE) will develop a demonstrable malignancy within five years of the initial diagnosis. Surgery has to be considered the best treatment for HGD or superficial carcinoma, but is contraindicated in patients with severe comorbidities. Non-surgical treatments such as intensive endoscopic surveillance, endoscopic ablative therapies, and endoscopic mucosal resection (EMR) have been proposed. EMR is a newly developed procedure promising to become a safe and reliable non-operative option for the endoscopic removal of HGD or early cancer within BE. It is important to assess the depth of invasion of the lesion and lymph node involvement before choosing EMR. This technique permits more effective staging of disease obtaining a large sample leading to a precise assessment of the depth of malignant invasion. Complications such as bleeding and perforation may occur, but can be treated endoscopically. Trials are needed to compare endoscopic therapy with surgical resection to establish clear criteria for EMR and ablative therapies.     

"Salvage" endoscopic mucosal resection in the colon using a retroflexion gastroscope dissection technique: a prospective analysis

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection and submucosal dissection can provide curative endoscopic therapy for Paris type I/II adenomas and node-negative early cancer. No studies have addressed the technical feasibility of retroflexion endoscopic dissection methods for luminal "salvage" therapy in patients considered unresectable using conventional forward-viewing resection. PATIENTS AND METHODS: Colonoscopy using an Olympus GIF-XQ240 gastroscope was carried out in 76 patients with Paris type I/II adenomas, early colorectal cancer (CRC), or laterally spreading tumors (LSTs) when the index endoscopist considered the lesion to be unresectable due to retrograde fold involvement. Endoscopic mucosal resection (EMR) and submucosal dissection were carried out using a complete retroflexion technique. Endoscopic and miniprobe 20-MHz or 12.5-MHz ultrasound follow-up data were collected prospectively up to 24 months after the index resection. RESULTS: Cecal intubation or cannulation to the neoterminal ileum was achieved in 76 (100 %) cases. Forty lesions (53 %) were classified in accordance with the Paris criteria as Is; 16 (21 %) as type II; 10 (13.5 %) as LST-G; and 10 (13.5 %) as LST-NG. Eight lesions (10 %) were excluded from EMR on the basis of endoscopic ultrasound criteria, with 68 of the 76 lesions (89 %) meeting the criteria for endoluminal resection. The median intubation time was 16 min (range 3-32 min). The median resection times were 98 min (range 30 - 242 min), 36 min (range 10-60 min), 172 min (range 20 - 240 min), and 60 min (range 10-116 min) for Paris Is, II, LST-G, and LST-NG lesions, respectively. LST-G morphology was associated with a high median submucosal injection volume in comparison with all other Paris types ( P < 0.05) and with a prolonged resection time ( P < 0.01). Sixty-one patients (94 %) completed the surveillance protocol. Higaki recurrence criteria were met in seven patients (11 %), with six undergoing successful adjunctive endoluminal resection. After 24 months of follow-up, the "cure" rate with endoscopic resection was 60 out of 61 (98 %). CONCLUSIONS: This is the first prospective study to address the safety and medium-term efficacy of retroflexion endoscopic resection in the colon. When appropriate exclusion criteria are applied, selected patients can receive curative resection using the retroflexion technique. "Salvage" endoluminal therapy may therefore be possible in such cases when surgical resection would otherwise have been required.