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 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 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 vs endoscopic mucosal resection for superficial esophageal cancer

AIM:To investigate the effectiveness of endoscopic submucosal dissection(ESD)and endoscopic mucosal resection(EMR)in treating superficial esophageal cancer(SEC).METHODS:Studies investigating the safety and efficacy of ESD and EMR for SEC were searched from the databases of Pubmed,Web of Science,EMBASE and the Cochrane Library.Primary end points included the en bloc resection rate and the curative resection rate.Secondary end points included operative time,rates of perforation,postoperative esophageal stricture,bleeding and local recurrence.The random-effect model and the fixed-effect model were used for statistical analysis.RESULTS:Eight studies were identified and included in the meta-analysis.As shown by the pooled analysis,ESD had significantly higher en bloc and curative resection rates than EMR.Local recurrence rate in the ESD group was remarkably lower than that in the EMR group.However,operative time and perforation rate for ESD were significantly higher than those for EMR.As for the rate of postoperative esophageal stricture and procedure-related bleeding,no significant difference was found between the two techniques.CONCLUSION:ESD seems superior to EMR in the treatment of SEC as evidenced by significantly higher en bloc and curative resection rates and by obviously lower local recurrence rate.     

内镜下黏膜剥离术治疗消化道黏膜增生性病变88例分析

目的探讨内镜下黏膜剥离术(ESD)治疗消化道黏膜增生性病变的临床疗效。方法将宜兴市人民医院收治的消化道黏膜增生性病变患者88例,随机分成内镜下黏膜切除术(EMR)组(44例)和ESD组(44例)。术后随访12个月,观察两组的临床疗效及穿孔、出血等并发症及复发情况。结果与EMR组比较,ESD组的手术时间明显增加,但一次性切除率明显升高(P0.05);术后6个月,ESD组切面愈合率显著高于EMR组(P0.05),ESD组术后12个月的复发率显著低于EMR组(P0.05)。结论与EMR相比,ESD治疗消化道黏膜增生性病变的一次性切除率和术后切面愈合率均较高,且术后12个月的复发率较低。     

An evaluation of resectability among endoscopic treatment methods for rectal neuroendocrine tumors <10 mm

Background and Study AimsWith respect to rectal neuroendocrine tumor (NET) resection, it remains unclear which of the following methods is the most effective: conventional endoscopic mucosal resection (cEMR), EMR using a fitted cap (EMR-C), EMR with a ligation band device (EMR-L), or endoscopic submucosal dissection (ESD). Thus, in this study, we aim to retrospectively evaluate the most effective endoscopic resection for rectal NETs < 10 mm.Patients and methodsIn total, 61 consecutive patients with primary rectal NETs < 10 mm in diameter were included in this study; they were then divided into three groups: those with cEMR; those with modified EMR (mEMR) involving EMR-C and EMR-L; and those with ESD. The primary endpoint was to evaluate the difference in the complete en bloc resection rate. The secondary endpoint was to investigate differences in procedure time and complications.ResultsAmong the three groups, a significant difference was found in procedure time (cEMR vs ESD, P < .01; mEMR vs ESD, P < .01), en bloc resection rate (cEMR vs mEMR, P = .015), tumor size (mEMR vs ESD, P < .01), percentage of tumor diameter ≥ 5 mm (mEMR vs ESD, P < .01), and complete en bloc resection rate (cEMR vs mEMR, P = .014). Meanwhile, no significant difference was noted in terms of complication rate among the three groups.ConclusionThe mEMR was the most suitable resection method for rectal NETs < 10 mm with respect to the risks and benefits from procedure-related factors, such as complete en bloc resection rate, procedure time, and complication rate.     

Endoscopic mucosal resection with a ligation device or endoscopic submucosal dissection for rectal carcinoid tumors: An analysis of 24 consecutive cases

Aims: Endoscopic submucosal dissection (ESD) has several advantages over conventional endoscopic mucosal resection, including a higher en bloc resection rate and more accurate pathological estimation. However, ESD is a complex procedure that requires advanced endoscopic skills. The aim of our study is to evaluate the efficacy of endoscopic mucosal resection with a ligation device (EMR‐L) compared to ESD for rectal carcinoid tumors. Methods: Between September 2003 and April 2011, 24 rectal carcinoid tumors in 24 patients treated by ESD or EMR‐L were retrospectively analyzed. The indications for endoscopic treatment were node‐negative rectal carcinoid tumors. We compared the therapeutic outcomes of the ESD group (n = 13) and the EMR‐L group (n = 11). Results: Both groups had similar mean tumor sizes (ESD: 5.5 ± 2.1 mm; EMR‐L: 4.4 ± 2.2 mm). The rates of en bloc and complete resection were, respectively, 100% and 92.3% for ESD, and 100% and 100% for EMR‐L. Perforations did not occur in either group. Postoperative bleeding occurred in one EMR‐L case, and it was endoscopically managed. However, there were no differences in therapeutic outcomes between the two groups. The mean procedure time was longer in the ESD group (28.8 ± 16.2 min) than in the EMR‐L group (17.4 ± 4.4 min), without a significant difference. The mean hospitalization period was significantly shorter in the EMR‐L group (1.8 ± 3.1 day) than in the ESD group (6.2 ± 2.1 day), and eight EMR‐L cases were treated in an outpatient setting. Conclusions: EMR‐L is a simple and effective procedure that compares favorably to ESD for small rectal carcinoid tumors.     

Indications for and Technical Aspects of Colorectal Endoscopic Submucosal Dissection

Due to the widespread acceptance of gastric and esophageal endoscopic submucosal dissections (ESDs), the number of medical facilities that perform colorectal ESDs has grown and the effectiveness of colorectal ESD has been increasingly reported in recent years. The clinical indications for colorectal ESD at the National Cancer Center Hospital, Tokyo, Japan include laterally spreading tumor (LST) nongranular type lesions >20 mm and LST granular type lesions >30 mm. In addition, 0-IIc lesions >20 mm, intramucosal tumors with nonlifting signs and large sessile lesions, all of which are difficult to resect en bloc by conventional endoscopic mucosal resection (EMR), represent potential candidates for colorectal ESD. Rectal carcinoid tumors less than 1 cm in diameter can be treated simply, safely, and effectively by endoscopic submucosal resection using a ligation device and are therefore not indications for ESD. The en bloc resection rate was 90%, and the curative resection rate was 87% for 806 ESDs. The median procedure time was 60 minutes, and the mean size for resected specimens was 40 mm (range, 15 to 150 mm). Perforations occurred in 23 (2.8%) cases, and postoperative bleeding occurred in 15 (1.9%) cases, but only two perforation cases required emergency surgery (0.25%). ESD was an effective procedure for treating colorectal tumors that are difficult to resect en bloc by conventional EMR. ESD resulted in a higher en bloc resection rate as well as decreased invasiveness in comparison to surgery. Based on the excellent clinical results of colorectal ESDs in Japan, the Japanese healthcare insurance system has approved colorectal ESD for coverage.     

Is Endoscopic Mucosal Resection a Sufficient Treatment for Low-Grade Gastric Epithelial Dysplasia?

Background/Aims

The rate of diagnosis of gastric adenoma has increased because esophagogastroduodenoscopy is being performed at an increasingly greater frequency. However, there are no treatment guidelines for low-grade dysplasia (LGD). To determine the appropriate treatment for LGD, we evaluated the risk factors associated with the categorical upgrade from LGD to high grade dysplasia (HGD)/early gastric cancer (EGC) and the risk factors for recurrence after endoscopic treatment.

Methods

We compared the complication rates, recurrence rates, and remnant lesions in 196 and 56 patients treated with endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR), respectively, by histologically confi rming low-grade gastric epithelial dysplasia.

Results

The en bloc resection rate was significantly lower in the EMR group (31.1%) compared with the ESD group (75.0%) (p<0.001). However, no significant difference was observed in the prevalence of remnant lesions or recurrence rate (p=0.911) of gastric adenoma. The progression of LGD to HGD or EGC caused an increase in the incidence of tumor lesions >1 cm with surface redness and depressions.

Conclusions

For the treatment of LGD, EMR resulted in a higher incidence of uncertain resection margins and a lower en bloc resection rate than ESD. However, there was no signifi cant difference in recurrence rate.     

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea

Endoscopic treatment,such as endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD),has been established as one of the treatment options for selected cases with early gastric cancer(EGC).Most studies on this topic have been carried out by researchers in Japan.Recently,the experience in EMR/ESD for EGC outside Japan is increasingly reported.In Korea,gastric cancer is the most common malignant disease,and the second leading cause of cancer death.Currently,EMR for EGC is widely performed i...     

Benefits of endoscopic submucosal dissection according to size and location of gastric neoplasm, compared with conventional mucosal resection

Background and Aims:  To clarify optimal therapeutic strategies for early gastric cancers without vestigial remnant or recurrence, we evaluated the benefits of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) according to tumor size and location.
Methods:  From January 2000 to December 2007, a total of 328 gastric lesions were treated using conventional EMR, while 572 lesions were treated by ESD. Patients who underwent surgery on the upper gastrointestinal tract before EMR or ESD were excluded from the study. We compared tumor size, location and rates of complete resection, curative resection, postoperative bleeding, perforation and local recurrence between EMR and ESD according to tumor situation.
Results:  Overall local complete resection rate (EMR, 64.2%; ESD, 95.1%) and overall curative resection rate (EMR, 59.5%; ESD, 82.7%) were significantly higher in ESD than in EMR. No significant differences were seen in complication rates between EMR and ESD. Local recurrence was detected in 13 lesions (4.0%) of the EMR group during follow up. In contrast, no local recurrence was detected in the ESD group. For lesions 5 mm or less in diameter, complete resection rate in the EMR group was not significantly inferior to that in the ESD group at any location. However, rates were overwhelmingly better in the ESD group than in the EMR group for lesions more than 5 mm in diameter, regardless of location.
Conclusion:  We concluded that lesions exceeding 5 mm in diameter should be treated by ESD, although a high resection rate is obtained also with EMR for lesions of 5 mm or less in diameter.     

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...     

EMR和ESD在消化道肿瘤治疗中的应用

考虑到外科手术的风险和改善患者生活质量等问题,内镜下粘膜切除术(EMR)和内镜下粘膜剥离术(ESD)在日本已成为消化道早期粘膜癌的常规治疗方法,并逐渐被西方等国家认同。现就EMR、ESD在消化道肿瘤治疗中的应用现状和进展作一综述。     

Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: A meta-analysis

AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Schol-ar and Cochrane library databases. Quality of each included study was assessed according to current Co-chrane guidelines. Primary endpoints were en bloc re-section rate and histologically complete resection rate. Secondary endpoints were length of procedure, post-treatment bleeding, post-procedural perforation and re-currence rate. Comparisons between the two treatment groups across all the included studies were performed by using Mantel-Haenszel test for fixed-effects mod-els(in case of low heterogeneity) or DerSimonian and Laird test for random-effects models(in case of high heterogeneity).RESULTS: Ten retrospective studies(8 full text and 2 abstracts) were included in the meta-analysis. Overall data on 4328 lesions, 1916 in the ESD and 2412 in the EMR group were pooled and analyzed. The mean operation time was longer for ESD than for EMR(stan-dardized mean difference 1.73, 95%CI: 0.52-2.95, P =0.005) and the "en bloc " and histological complete re-section rates were significantly higher in the ESD group [OR = 9.69(95%CI: 7.74-12.13), P 0.001 and OR = 5.66,(95%CI: 2.92-10.96), P 0.001, respectively]. As a consequence of its greater radicality, ESD provided lower recurrence rate [OR = 0.09,(95%CI: 0.05-0.17), P 0.001]. Among complications, perforation rate was significantly higher after ESD [OR = 4.67,(95%CI, 2.77-7.87), P 0.001] whereas the bleeding incidences did not differ between the two techniques [OR = 1.49(0.6-3.71), P = 0.39].CONCLUSION: In the endoscopic therapy of EGC, ESD showed a superior efficacy but higher complication rate with respect to EMR.     

Importance of histological evaluation in endoscopic resection of early colorectal cancer

The diagnostic criteria for colonic intraepithelial tumors vary from country to country.While intramucosal adenocarcinoma is recognized in Japan,in Western countries adenocarcinoma is diagnosed only if the tumor invades to the submucosa and accesses the muscularis mucosae.However,endoscopic therapy,including endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD),is used worldwide to treat adenoma and early colorectal cancer.Precise histopathological evaluation is important for the curativeness of these therapies as inappropriate endoscopic therapy causes local recurrence of the tumor that may develop into fatal metastasis.Therefore,colorectal ESD and EMR are not indicated for cancers with massive submucosal invasion.However,diagnosis of cancer with massive submucosal invasion by endoscopy is limited,even when magnifying endoscopy for pit pattern and narrow band imaging and flexible spectral imaging color of enhancement are performed.Therefore,occasional cancers with massive submucosal invasion will be treated by ESD and EMR.Precise histopathological evaluation of these lesions should be performed in order to determine the necessity of additional therapy,including surgical resection.     

Treatment modalities for early gastric cancer

Different treatment modalities have been proposed in the treatment of early gastric cancer (EGC). Endoscopic resection (ER) is an established treatment that allows curative treatment, in selected cases. In addition, ER allows for an accurate histological staging, which is crucial when deciding on the best treatment option for EGC. Recently, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have become alternatives to surgery in early gastric cancer, mainly in Asian countries. Patients with “standard” criteria can be successfully treated by EMR techniques. Those who meet “expanded” criteria may benefit from treatment by ESD, reducing the need for surgery. Standardized ESD training system is imperative to promulgate effective and safe ESD technique to practices with limited expertise. Although endoscopic resection is an option in patients with EGC, surgical treatment continues to be a widespread therapeutic option worldwide. In this review we tried to point out the treatment modalities for early gastric cancer.     

内镜黏膜下剥离术在治疗胃肠道黏膜切除术后残留和复发病灶中的应用

目的 探讨内镜黏膜下剥离术(ESD)治疗胃肠道黏膜切除术(EMR)后残留、复发病变的疗效和安全性.方法 自2006年6月至2007年11月对EMR术后内镜随访发现的15例残留和复发病变进行ESD治疗,先于黏膜下注射生理盐水以抬高病变,接着预切开病变周围黏膜,再沿病变下方黏膜下层进行剥离,对瘢痕形成部位直接应用Hook刀沿瘢痕基底切线方向进行切开.结果 15例EMR术后残留和复发病变,位于胃6例、结肠3例、直肠6例,病变直径0.8～3.5 cm,平均2.3 cm.所有病变抬举征(一).14例病变成功完成ESD治疗,成功率93.3%(14/15),13例术后病理切缘和基底无肿瘤累及,完整切除率86.7%(13/15).ESD手术时间60～155 min,平均87 min.治疗中创面均有少量出血,全组未出现术后出血.2例治疗中局部剥离较深、腹腔出现游离气体,成功保守治疗,未转外科手术,ESD穿孔发生率13.3%(2/15).术后平均随访13个月,无复发.结论 ESD治疗EMR术后残留和复发病变相对安全、有效,不仅能完整切除残留和复发病变,还能提供完整的病理诊断资料.     

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.     

Effectiveness of circumferential endoscopic mucosal resection with a novel tissue-anchoring device

AIM: To evaluate the efficacy of circumferential endoscopic mucosal resection (EMR) with a tissue-anchoring device in comparison to forceps precut EMR and conventional endoscopic submucosal dissection (ESD). METHODS: The study was designed as a prospective, randomized, ex vivo study. Fresh ex vivo specimens were harvested from adult white Yorkshire pigs weighing 30-50 kg. Seventy-five standardized, artificial lesions measuring 3 cm × 3 cm were created by methy- lene blue tattoo at the greater curvature in fresh ex vivo stomachs using the EASIE-R simulator platform (Endosim LLC, Berlin, MA, United States). The three advanced endoscopists performed the three resection techniques such as circumferential EMR using the tissue-anchoring device (TA-EMR), forceps precut EMR (FP-EMR), and endoscopic submucosal dissection. The endoscopists and the type of cutting methods were determined randomly by grouped randomized selection.The resection bed was grossly inspected to determine whether the lesion was resected "en-bloc " (defined as no remaining mucosal tattoo remaining on specimen). The resection bed was also probed for evidence of perforation. The procedural time of circumferential resection, submucosal dissection, and injection frequency were recorded by an independent observer.RESULTS: All 75 created lesions were successfully resected by three advanced endoscopists using the three techniques. The mean ± SD size of resected specimens (long axis) were 39.5 ± 5.6 mm, 36.5 ± 7.3 mm, and 44.6 ± 5.6 mm for TA-EMR, FP-EMR, and ESD respectively. The overall mean dissection time of both the TA- EMR and FP-EMR was significant shorter than ESD (TA- EMR: 5.1 ± 3.3 min, FP-EMR: 3.5 ± 2.0 min vs ESD: 15.8 ± 9.5 min, P 0.001, P 0.001). The overall mean total procedure time of both the tissue-anchoring and forceps circumferential EMR was significantly shorter than ESD (TA-EMR: 17.5 ± 6.0 min, FP-EMR: 16.6 ± 6.6 min vs ESD: 28.6 ± 13.9 min, P 0.001, P 0.001). The en-bloc resection rate of ESD was 100% (25/25) and the en-bloc resection rate of the TA-EMR (84.0%, 21/25) was higher than for the FP-EMR (60.0%, 15/25), yet not statistically significant (P = 0.18). The perforation rate of each technique was 8.0% (2/25). CONCLUSION: TA-EMR appears to be quicker than ESD, and there was a trend towards improved en bloc resection rate with the TA-EMR when compared to the FP-EMR.     

阑尾腔内息肉内镜下治疗的初步观察

2016年1月—2020年12月间,在首都医科大学附属北京友谊医院消化内科行内镜下治疗的阑尾腔内息肉病例共6例,息肉直径0.3~1.3 cm。6例阑尾腔内息肉均顺利完成内镜下治疗,其中3例行内镜黏膜切除术整块切除、1例行内镜黏膜切除术分片切除、1例行内镜黏膜下剥离术切除、1例予活检钳冷钳除。6例术后均未出现出血、穿孔、感染和急性阑尾炎等并发症。3例术后复查创面愈合良好、无复发,其余3例暂未复查结肠镜。以上结果初步证实,阑尾腔内息肉行内镜下治疗安全和有效。