Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis

Objective A prospective technical feasibility study of cap assisted ESD for ‘curative intent’ in patients with residual or local neoplastic recurrence following EMR. Primary end points were second stage R0 resection rate, safety and recurrence. Method Salvage ESD was performed using the Olympus GIF‐XQ240 gastroscope and KD‐630L insulation tipped knife. Thirty‐day mortality, re‐admission rates, complications and histological resection status were collected prospectively up to 9 months following index resection. Results Thirty patients met eligibility criteria. Index R0 resection was achieved in 25/30 (83%) lesions. One patient underwent surgical excision with a second receiving a curative second stage dissection. Ninety‐six per cent (29/30) patients were discharged within 24 h of the procedure with a 0% 30‐day mortality and re‐admission rate. Bleeding occurred in 5/30 (16%) treated successfully with endoluminal haemostasis. There were no perforations. Overall ‘cure’ rates at short‐term follow‐up [median 6/12 (range; 3–18)] was 96%. Conclusion This novel application of ESD for first line ‘salvage’ therapy in treating residual or locally recurrent neoplastic disease may be a safe, minimally invasive and cost effective alternative to direct surgical resection in a select patient cohort.     

内镜黏膜剥离结合圈套器治疗大型浅表结直肠肿瘤

目的探讨采用内镜黏膜剥离结合圈套器治疗大型浅表结直肠肿瘤的价值。方法前瞻性研究36例大型浅表结直肠肿瘤（直径／〉2．0cm）,非随机分为2组,采用黏膜剥离结合圈套器治疗21例（A组）,黏膜剥离术治疗15例（B组）,比较两组手术的临床指标及术后结肠镜随访情况。结果两组患者的一般资料相似,差异无统计学意义（P〉0．05）,具有可比性。A组在手术时间和术中出血量方面优于B组,差异有统计学意义（P〈0．05）;而两组在肿瘤直径、术后出血量、术后复发等方面,差异无统计学意义（P〉0．05）。结论内镜黏膜剥离结合圈套器治疗大型浅表结直肠肿瘤,可缩短手术时间,减少术中出血,安全可行。     

内镜下切除技术对食管胃连接部胃肠间质瘤的治疗价值

目的评价以内镜黏膜下剥离术（ESD）为基础的内镜下切除术在食管胃连接部（EGJ）胃肠间质瘤（GIST）治疗中的安全性及有效性。方法收集复旦大学附属中山医院内镜中心所有接受ESD治疗的患者资料．筛选出2007年11月至2011年6月间经病理证实的EGJ处GIST患者20例．总结并分析其临床病理及术后随访资料。结果20例EGJ处GIST均起源于固有肌层,其中男性11例,女性9例,年龄29～67（平均54．1）岁,病灶直径8-20（平均14．8）mm。所有病例均成功完成内镜切除手术．其中15例接受了内镜黏膜下挖除术．4例接受了无腹腔镜辅助的内镜全层切除术。1例接受了内镜经黏膜下隧道肿瘤切除术。手术时间15-90（平均47．8）min,术中出血量5-200ml,病灶的完整切除率为100％。术中穿孔4例,气腹3例,气胸1例,贲门黏膜撕裂1例,均通过内镜下处理及保守治疗恢复。20例患者术后均接受了3-36（平均13-2）个月的随访,无局部复发和远处转移病例。结论在EGJ处GIST的治疗中,以ESD为基础的内镜下切除技术是一种安全和有效的治疗手段。     

内镜黏膜下剥离术治疗消化道粘膜下肿瘤的围手术期护理

目的总结内镜粘膜下剥离术(ESD)治疗消化道粘膜下肿瘤的护理要点。方法对38例消化道黏膜下肿瘤患者采用ESD治疗,配以熟练的配合和细致的护理。结果术中7例出现不同程度的出血,予热活检钳止血后出血停止,2例迟发性出血,量较少,药物治疗及禁食后症状好转。术中出现穿孔2例,其中1例送外科手术治疗,另1例用钛夹夹闭后胃肠减压,24小时后症状缓解。术后无出现穿孔、感染等并发症。结论 ESD是治疗消化道粘膜下肿瘤安全有效的微创技术,熟练的术中配合及细致的护理是顺利完成ESD及减少并发症的有效保障。     

内镜下黏膜切除术及黏膜剥离术治疗早期胃癌和癌前病变的疗效对比研究

目的对比分析内镜下黏膜切除术（EMR）和内镜下黏膜剥离术（ESD）对治疗早期胃癌（EGC）和癌前病变的效果和安全性。 方法选取2015年1月至2016年1月无锡市第二人民医院收治的60例EGC和癌前病变患者为研究对象,根据治疗方式分为EMR组（32例）和ESD组（28例）,对比分析两组患者的手术时间、禁饮禁食时间、术中出血情况、术后病理、整块切除率、治愈性切除率、肿瘤局部复发率、肿瘤残留率和术中、术后不良反应及预后情况。 结果ESD组患者手术时间长于EMR组［（53.35±7.12）min vs（34.23±5.74）min,t=2.009,P=0.043］,术中出血量多于EMR组［（10.26±3.42）ml vs（3.35±0.71）ml,t=2.511,P=0.018］,差异有统计学意义。ESD组患者病灶整块切除率（92.9% vs 62.5%,χ²=7.693,P=0.006）及治愈性切除率（78.6% vs 43.8%,χ²=7.545,P=0.006）均高于EMR组患者,差异有统计学意义。ESD组不良反应率为14.3%（4/28）,高于EMR组的3.1%（1/32）,差异有统计学意义（χ²=8.765,P=0.001）。两组患者术后2年总生存率比较,差异无统计学意义（χ²=0.643,P=0.423）。 结论与EMR相比,ESD可能是治疗EGC及癌前病变的一种较为安全有效的手术方式。     

Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction

BACKGROUNDEndoscopic resection approaches, including endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR), have been widely used for the treatment of submucosal tumors (SMTs) located in the upper gastrointestinal tract. However, compared to SMTs located in the esophagus or stomach, endoscopic resection of SMTs from the esophagogastric junction (EGJ) is much more difficult because of the sharp angle and narrow lumen of the EGJ. SMTs originating from the muscularis propria (MP) in the EGJ, especially those that grow extraluminally and adhere closely to the serosa, make endoscopic resection even more difficult.AIMTo investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.METHODSA total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study. The difficulty of endoscopic resection was defined as a long procedure time, failure of en bloc resection and intraoperative bleeding. Clinicopathological, endoscopic and follow-up data were collected and analyzed. Statistical analysis of independent risks for piecemeal resection, long operative time, and intraoperative bleeding were assessed using univariate and multivariate analyses.RESULTSAccording to the location and growth pattern of the tumor, 44 patients underwent STER, 14 patients underwent EFTR, and the remaining 32 patients received a standard ESD procedure. The tumor size was 20.0 mm (range 5.0–100.0 mm). Fourty-seven out of 90 lesions (52.2%) were regularly shaped. The overall en bloc resection rate was 84.4%. The operation time was 43 min (range 16–126 min). The intraoperative bleeding rate was 18.9%. There were no adverse events that required therapeutic intervention during or after the procedures. The surgical approach had no significant correlation with en bloc resection, long operative time or intraoperative bleeding. Large tumor size (≥ 30 mm) and irregular tumor shape were independent predictors for piecemeal resection (OR: 7.346, P = 0.032 and OR: 18.004, P = 0.029, respectively), long operative time (≥ 60 min) (OR: 47.330, P = 0.000 and OR: 6.863, P = 0.034, respectively) and intraoperative bleeding (OR: 20.631, P = 0.002 and OR: 19.020, P = 0.021, respectively).CONCLUSIONEndoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ. Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.     

A meta-analysis of the effect of endoscopic submucosal dissection compared with gastrectomy on the wound infection in early stomach cancer subjects

We conducted a meta-analysis to assess the effect of endoscopic submucosal dissection compared with gastrectomy on the wound infection in early stomach cancer subjects. A systematic literature search up to November 2022 was performed and 2765 related studies were evaluated. The chosen studies comprised 7842 early stomach cancer subjects participated in the selected studies' baseline trials; 3308 of them used the endoscopic submucosal dissection, while 4534 used gastrectomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the wound infection in endoscopic submucosal dissection versus gastrectomy for early stomach cancer by the dichotomous methods with a random or fixed effect model. The use of endoscopic submucosal dissection resulted in significantly lower wound infection (OR, 0.45; 95% CI, 0.34–0.60, P < .001) with no heterogeneity (I² = 8%) compared with the gastrectomy for early stomach cancer. The use of endoscopic submucosal dissection resulted in significantly lower wound infection compared with the gastrectomy for early stomach cancer. The small sample size of some studies in the comparison calls for care when analysing the results.     

Different solutions used for submucosal injection influenced early healing of gastric endoscopic mucosal resection in a preclinical study in experimental pigs

Background  We hypothesised that different solutions for submucosal injection may influence early healing of endoscopic mucosal resection (EMR). The aim of this study was to evaluate histological and immunological changes after EMR in experimental pigs. Materials and methods  Two parallel EMRs on the anterior and posterior wall of the gastric body were performed by means of the cap technique in 21 female pigs. A glycerol-based solution (anterior EMR) and hydroxypropyl methylcellulose solution (posterior EMR) were applied for submucosal injection. The animals were sacrificed 7 days later, and tissue sections of all EMRs were stained using combined trichrome. Computer image analysis was used for objective evaluation of elastic and collagen fibres content. Two-colour indirect immunophenotyping of blood and gastric samples were performed using mouse anti-pig monoclonal antibodies. Results  The values of collagen fibre content 7 days after EMR were significantly higher in lesions after the use of solution A in comparison with solution B (2.10 ± 0.25% versus 1.57 ± 0.25%, p = 0.009). Concordant results were found in elastic fibres (3.23 ± 0.49% versus 2.93 ± 0.61%, p = 0.018). No systemic changes in major leukocyte subpopulations were found. In gastric tissue, lymphocyte subsets exhibited only minor changes. CD4⁺ T-lymphocytes were increased in the healing tissue after EMR using solution A (17.08 ± 9.24% versus 9.76 ± 7.97%, p = 0.011). Significant increase of SWC3⁺ leukocytes was observed after EMR using solution B (47.70 ± 25.41% versus 18.70 ± 12.16%, p = 0.001). Conclusions  The use of glycerol-based solution for submucosal injection was associated with more pronounced histological signs of early healing of EMRs compared with hydroxypropyl methylcellulose. This work was presented in part at the 15th United European Gastroenterology Week, October 2007, Paris, France (histochemical study) and at the Digestive Disease Week, May 2008, San Diego, California, USA (immunological study).     

内镜黏膜下剥离术治疗结直肠侧向发育型肿瘤的疗效

目的探讨直径〉2em的结直肠侧向发育型肿瘤（LST）的病理特点,评估内镜黏膜下剥离术（ESD）治疗结直肠LST的疗效及安全性。方法回顾性分析2007年12月至2011年4月复旦大学附属中山医院收治的151例结直肠LST患者的临床资料。根据内镜下表面形态将151例LST进行分型,统计各型LST的部位、大小、形态特征,然后对LST的临床病理特点以及ESD治疗的切除率、手术时问、并发症和复发情况进行分析。采用K系数检验分析LST亚型一致性。结果151例患者中,结直肠LST分布依次为：直肠58例、升结肠47例、盲肠15例、横结肠14例、乙状结肠13例、降结肠4例。病变直径为（3．4±1．2）em。颗粒型结直肠LST105例,其中结节混合型75例,颗粒均一型30例;非颗粒型结直肠LST46例,其中扁平隆起型31例,假凹陷型15例。两型分型一致系数K为0．87,四亚型分型一致系数K为0．80。腺瘤伴有低级别瘤变96例、高级别上皮内瘤变44例、黏膜下癌11例。腺瘤中管状绒毛状腺瘤58例、管状腺瘤33例、绒毛状腺瘤3例、锯齿状腺瘤2例。整块切除率为98．01％（148／151）,完整切除率为94．70％（143／151）,完整治愈切除率为90．73％（137／151）。手术时间为（52±31）min,ESD术后出血发生率为3．97％（6／151）,穿孔发生率为3．31％（5／151）。平均随访时间为28．6个月,复发率为0．66％（1／151）。结论直径〉2cm的结直肠LST病变存在较高的恶变潜能。ESD治疗LST病变整块切除率高,复发率较低,是结直肠LST病变安全且有效的治疗方法。     

早期胃癌行内镜黏膜下剥离术非治愈性切除后追加外科手术时机选择研究

目的 探讨早期胃癌行内镜黏膜下剥离术（ESD）非治愈性切除后追加外科手术的时机。方法 回顾性分析2011年3月至2017年3月于南京大学医学院附属鼓楼医院诊断早期胃癌行ESD非治愈性切除后90 d内追加外科根治手术90例,排除失访7例,最终纳入83例。根据追加外科手术的时间分为早期手术组（ESD后≤29 d,52例）和延迟手术组（ESD后30~90 d,31例）。比较两组病人术中出血量、手术时间、术后并发症、术后住院时间、淋巴结阳性率、胃病灶阳性率、复发率、总体存活率和无病存活率。进一步分析ESD非治愈性切除病人淋巴转移的危险因素。结果 两组病人一般资料比较,差异无统计学意义。中位随访时间64个月,两组的3年无病生存率差异无统计学意义（96.2% vs. 96.8%,P=0.884）。与早期手术组相比,延迟手术组的术中出血量减少（P=0.011）。两组的手术时间、术后住院时间、术后并发症发生率差异无统计学意义。延迟手术组的淋巴结转移率（12.9%） 高于早期手术组（5.8%）,但两者比较差异无统计学意义（P=0.258）。脉管癌栓是淋巴转移的独立危险因素（OR=5.956,95%CI：0.017-0.641,P=0.015）。结论 早期胃癌ESD非治愈性切除后,延迟手术组相比早期手术组的术中出血量减少,生存预后差异无统计学意义。有脉管癌栓危险因素,根据病人的情况建议适当缩短手术等待时间。     

Technical solutions to improve the management of non‐muscle‐invasive transitional cell carcinoma: summary of a European Association of Urology Section for Uro‐Technology (ESUT) and Section for Uro‐Oncology (ESOU) expert meeting and current and future perspectives

The aim of the present review was to compare state‐of‐the‐art care and future perspectives for the detection and treatment of non‐muscle‐invasive transitional cell carcinoma (TCC) of the bladder. We provide a summary of the third expert meeting on ‘Optimising the management of non‐muscle‐invasive bladder cancer, organized by the European Association of Urology Section for Uro‐Technology (ESUT) in collaboration with the Section for Uro‐Oncology (ESOU), including a systematic literature review. The article includes a detailed discussion on the current and future perspectives for TCC, including photodynamic diagnosis, optical coherence tomography, narrow band imaging, the Storz Professional Image Enhancement system, magnification and high definition techniques. We also provide a detailed discussion of future surgical treatment options, including en bloc resection and tumour enucleation. Intensive research has been conducted to improve tumour detection and there are promising future perspectives, that require proven clinical efficacy. En bloc resection of bladder tumours may be advantageous, but is currently considered to be experimental.