Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm

Background and Aims: Colorectal laterally spreading tumors (LST) > 20 mm are usually treated by endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR). Endoscopic piecemeal mucosal resection (EPMR) is sometimes required. The aim of our study was to compare the outcomes of ESD and EMR, including EPMR, for such LST. Methods: A total of 269 consecutive patients with a colorectal LST > 20 mm were treated endoscopically at our hospital from April 2006 to December 2009. We retrospectively evaluated the complications and local recurrence rates associated with ESD, hybrid ESD (ESD with EMR), EMR, and EPMR. Results: ESD and EMR were performed successfully for 89 and 178 LST, respectively: 61 by ESD; 28 by hybrid ESD; 70 by EMR; and 108 by EPMR. Between‐group differences in perforation rates were not significant. Local recurrence rates in cases with curative resection were as follows: 0% (0/56) in ESD; 0% (0/27) in hybrid ESD; 1.4% (1/69) in EMR; and 12.1% (13/107) in EPMR; that is, significantly higher in EPMR. No metastasis was seen at follow up. The recurrence rate for EPMR yielding ≥ three pieces was significantly high (P < 0.001). All 14 local recurrent lesions were adenomas that were cured endoscopically. Conclusions: As for safety, ESD/hybrid ESD is equivalent to EMR/EPMR. ESD/hybrid ESD is a feasible technique for en bloc resection and showed no local recurrence. Although local recurrences associated with EMR/EPMR were seen, which were conducted based on our indication criteria, all local recurrences could obtain complete cure by additional endoscopic treatment.     

Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer

BACKGROUND: In EMR of early gastric cancer (EGC), en bloc resection reduces the risk of residual cancer. Endoscopic submucosal dissection (ESD) now allows en bloc resection of large EGCs. OBJECTIVE: To retrospectively determine whether ESD is more advantageous than EMR for EGCs. DESIGN: EMR (825 lesions, 711 patients) or ESD (195 lesions, 185 patients) was performed. The en bloc resection rate, histologically complete resection rate, operation time, complications, and local recurrence rate were studied in relation to ulceration. SETTING: Hiroshima University Hospital. PATIENTS: Subjects comprised 896 patients in whom 1020 EGCs were resected endoscopically from 1990 to 2004. RESULTS: In cases without ulceration, en bloc and histologically complete resection rates were significantly higher with ESD than with EMR, regardless of tumor size. The frequency of ulceration did not differ significantly between groups. Average operation time was significantly longer for ESD than for EMR, regardless of tumor size. Also, regardless of ulceration, the incidence of intraoperative bleeding was significantly higher with ESD (22.6%) than with EMR (7.6%). Delayed bleeding did not differ. In cases with ulceration, the incidence of perforation was significantly higher with ESD (53.8%) than with EMR (2.9%). Local recurrences were treated by incomplete EMR (en bloc, 2.9%; piecemeal, 4.4%). No patient experienced recurrence after ESD. CONCLUSIONS: ESD increased en bloc and histologically complete resection rates and may reduce the local recurrence rate. Increased operation time and complication risks with ESD in comparison with EMR remain problematic. Special measures are necessary for ESD of ulcerated lesions to reduce the rates of perforation and incomplete resection.     

Comparing endoscopic submucosal dissection with transanal resection for non-invasive rectal tumor: a retrospective study

Background and Aim: Endoscopic submucosal dissection (ESD) is an alternative to transanal resection (TAR) in treating rectal adenomas, intramucosal cancers, and superficial submucosal cancers. The purpose of this study is to compare the clinical efficacy between ESD and TAR for non‐invasive rectal tumors. Methods: Between January 1998 and December 2006, 85 patients with preoperative diagnosis of non‐invasive rectal tumors were treated by ESD or TAR. En‐bloc resection, local recurrence, complication, procedure time, and hospital stay were evaluated retrospectively using a prospectively‐completed database. Results: Mean resection sizes were 40 mm and 39 mm in diameter for the ESD and TAR groups, respectively. En‐bloc resections with a negative resection margin were achieved in 67% (35/52) of the ESD group, which was significantly higher than the 42% (14/33) in the TAR group. Sixty‐three lesions were diagnosed as curative resection, histopathologically. There was no local recurrence in the ESD group, but five local recurrences developed in the TAR group. Two rectal perforations, one minor delayed bleeding, and one subcutaneous emphysema in the ESD group were successfully managed conservatively. There were one minor delayed bleeding and two anesthesia‐related complications in the TAR group. The ESD group had a shorter hospital stay than the TAR group (4.9 days vs 7 days), but a longer procedure time (131 min vs 63 min). Conclusion: ESD was more effective than TAR in treating non‐invasive rectal tumors, with a lower recurrence rate and shorter hospital stay.     

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.     

Advantages of endoscopic submucosal dissection versus endoscopic oblique aspiration mucosectomy for superficial esophageal tumors

Background and Aim: In the treatment of superficial esophageal tumors (SET), en bloc histologically‐complete resection reduces the risk of local recurrence. Endoscopic oblique aspiration mucosectomy (EOAM) and endoscopic submucosal dissection (ESD) have been applied to resect SET. The aim of this study was to retrospectively determine whether ESD is more advantageous than EOAM for SET. Methods: In the present study, there was a total of 122 patients in whom 162 SET were resected endoscopically at Hiroshima University Hospital. EOAM (83 lesions/63 patients) or ESD (79 lesions/59 patients) was performed. En bloc histologically‐complete resection rates, operation time, complications, and the local recurrence rate were studied. Results: In SET > 20 mm, the en bloc histologically‐complete resection rate was significantly higher with ESD than with EOAM (94% vs 42%, P < 0.001). In SET of 16–20 mm, the rate tended to be higher with ESD than with EOAM (100% vs 81%, P = 0.08). In SET < 15 mm, the rates did not differ significantly between groups. The average operation time was significantly longer for ESD than for EOAM, regardless of tumor size (49.7 ± 33.0 min vs 19.1 ± 6.1 min, P < 0.001). Complication rates did not differ significantly between groups. The local recurrence rate was significantly lower with ESD than with EOAM (0%, mean observation period: 18.9 months vs 9%, mean observation period: 30.7 months, P = 0.03). Conclusion: Although increased operation time with ESD remains problematic, SET >15 mm should be treated with ESD to reduce local recurrence. In lesions ≤15 mm, EOAM might be preferable, especially in high‐risk patients.     

Usefulness of sodium hyaluronate solution in colorectal endoscopic mucosal resection

Background: In endoscopic mucosal resection (EMR), it is essential to inject submucosal fluid to prevent complications and ensure safe and complete en bloc resection of tumors. Sodium hyaluronate (SH) solution, which is effective in forming and maintaining a mucosal lift and is innocuous to mucosal tissue, is considered a useful injection solution for endoscopic submucosal dissection, a procedure associated with a high risk of perforation. This study was undertaken to assess the usefulness of this solution in EMR. Methods: Ninety‐four patients with colorectal tumors of ≤20 mm in diameter were enrolled for this study and randomized to a SH solution group (0.2% two‐fold diluted MucoUp) or to a normal saline group (control). Ease of EMR was primarily assessed based on ease of submucosal injection, ease of snaring and injection time. Results: SH solution was superior to normal saline for ease of submucosal injection (57 ± 0.7 vs 50 ± 0.7; P < 0.05), and it showed better results for ease of snaring with less variability (63 ± 0.8 vs 51 ± 1.0; P < 0.05). The mean injection time was similar between the two groups (3.0 ± 9.0 s and 3.0 ± 2.7 s, respectively). Post‐procedural hemorrhage occurred in 7% patients (3/46) injected with SH solution and in 6% of patients (3/48) in the control group; there was no significant difference between the groups. Conclusions: Use of two‐fold diluted MucoUp facilitated colorectal EMR.     

Colorectal endoscopic submucosal dissection: present status and future perspective,including its differentiation from endoscopic mucosal resection

Endoscopic submucosal dissection (ESD) allows en bloc resection of a lesion, irrespective of the size of the lesion. ESD has been established as a standard method for the endoscopic ablation of malignant tumors in the upper gastrointestinal (GI) tract in Japan. Although the use of ESD for colorectal lesions has been studied via clinical research, ESD is not yet established as a standard therapeutic method for colorectal lesions because colorectal carcinoma has unique pathological, organ specific characteristics that differ radically from those of the esophagus and stomach, and scope handling and control is more difficult in the colorectum than in the upper GI tract. Depending on the efficacy of endoscopic mucosal resection (EMR) and the clinicopathological characteristics of the colorectal tumor, the proposed indications for colorectal ESD are as follows: (1) lesions difficult to remove en bloc with a snare EMR, such as nongranular laterally spreading tumors (particularly the pseudo depressed type), lesions showing a type VI: pit pattern, and large lesions of the protruded type suspected to be carcinoma; (2) lesions with fibrosis due to biopsy or peristasis; (3) sporadic localized lesions in chronic inflammation such as ulcerative colitis; and (4) local residual carcinoma after EMR. Colorectal ESD is currently in the development stage, and a standard protocol will be available in the near future. We hope that colorectal tumors will be efficiently treated by a treatment method appropriately selected from among EMR, ESD, and surgical resection after precise preoperative diagnosis based on techniques such as magnifying colonoscopy.     

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.     

Safe procedure in endoscopic submucosal dissection for colorectal tumors focused on preventing complications

Endoscopic submucosal dissection (ESD) is efficient for en bloc resection of large colorectal tumors. However, it has several technical difficulties, because the wall of the colon is thin and due to the winding nature of the colon. The main complications of ESD comprise postoperative perforation and hemorrhage, similar to endoscopic mucosal resection (EMR). In particular, the rate of perforation in ESD is higher than that in EMR. Perforation of the colon can cause fatal peritonitis. Endoscopic clipping is r...     

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.     

Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection

BACKGROUND: A new technique, endoscopic submucosal dissection (ESD), which uses specially developed endoscopic knives, was recently developed for en bloc resection of large lesions. Despite increasing indications for endoscopic resection (ER), there are limited data available regarding the outcome of ER for lesions 20 mm or more in diameter. OBJECTIVE: To investigate the risk factors for local recurrence. DESIGN: Retrospective cohort study. SETTING: A cancer-referral center. PATIENTS: Seventy patients, who presented between September 1994 and April 2006, with a total of 78 lesions that measured 20 mm or more in diameter. MAIN OUTCOME MEASUREMENT: Local recurrence rate after ER was assessed. RESULTS: At a median follow-up of 32 months (range 12-121 months), there were 12 local recurrences (15.4%). There was no significant association between local recurrence and multiple iodine-voiding lesions, tumor size, or tumor location. The number of resections and the resection method, however, were significantly associated with local recurrence. There was no recurrence of lesions treated by en bloc resection. Lesions resected in 5 or more pieces had a significantly higher recurrence rate than lesions resected in 2 to 4 pieces. Lesions treated by EMR had a significantly higher recurrence rate than lesions treated by ESD. LIMITATIONS: Single-center retrospective analysis. CONCLUSIONS: Esophageal squamous-cell carcinoma that measured 20 mm or more in diameter should be resected en bloc by ESD. Lesions treated by resection in 5 or more pieces have a higher risk for local recurrence.     

Colorectal endoscopic submucosal dissection: Systematic review of mid‐term clinical outcomes

With a drive towards minimally invasive surgery, endoscopic submucosal dissection (ESD) is now gaining popularity. In a number of East Asian countries, ESD is now the treatment of choice for early non‐metastatic gastric cancer, but the outcomes of ESD for colorectal lesions are unclear. The present review summarizes the mid‐term outcomes of colorectal ESD including complication and recurrence rates. A systematic literature search was done in May 2014, identifying 20 publications reporting the outcomes of colorectal ESD which were included in this review. En‐bloc resection rates, complete (R0) resection rates, endoscopic clearance rates, complication and recurrences rates were analyzed. Statistical pooling was done to calculate weighted means using random effects modeling. Twenty studies reporting the outcomes of 3060 colorectal ESD procedures were reported. Overall weighted en‐bloc resection rate was 89% (95% CI: 83–94%), R0 resection rate 76% (95% CI: 69–83%), endoscopic clearance rate 94% (95% CI: 90–97%) and recurrence rate 1% (95% CI: 0.5–2%). Studies that followed up patients for over 1 year were found to have an en‐bloc resection rate of 91% (95% CI: 86–96%), R0 resection rate of 81% (95% CI: 75–88%), endoscopic clearance rate 93% (95% CI: 90–97%) and recurrence rate of 0.8% (95% CI: 0.4–1%). Colorectal ESD can be carried out effectively and safely with a 1% recurrence rate. Further studies with longer follow‐up periods are required to determine whether colorectal ESD is a viable alternative to conventional surgical therapy.     

Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal tumors: A meta-analysis

AIM: To compare the efficacy and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for the treatment of colorectal tumors.METHODS: Databases, such as PubMed, EMBASE, Cochrane Library and Science Citation Index updated to 2013 were searched to include eligible articles. In the meta-analysis, the main outcome measurements were the en bloc resection rate, the histological resection rate and the local recurrence rate. Meanwhile, we also compared the operation time and the incidence of procedure-related complications.RESULTS: Six trials were identified and a total of 1642 lesions were included. The en bloc resection rate was higher and the local recurrence rate was lower in the ESD group compared with the EMR group (OR = 7.94; 95%CI: 3.96-15.91; OR = 0.09; 95%CI: 0.04-0.19). There was no significant difference in histological resection rate(OR = 1.65; 95%CI: 0.29-9.30) and procedure-related complication rate between the two groups (OR = 1.59; 95%CI: 0.92-2.73). The meta-analysis also showed that ESD was more time consuming than EMR.CONCLUSION: Compared with EMR, ESD results in higher en bloc resection rate and lower local recurrence rate for the treatment of colorectal tumors, without increasing the procedure-related complications.     

Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection

BACKGROUND: EMR is currently a standard treatment for mucosal gastric tumors. Endoscopic submucosal dissection (ESD) has been developed for en bloc resection. OBJECTIVE: We evaluated the clinical outcomes of ESD compared with conventional EMR. DESIGN: Not applicable. SETTING: A historical control study was performed between EMR and ESD. PATIENTS: EMR of 245 gastric tumors was performed in 229 patients. Lesions were divided into two groups. Conventional EMR was performed in group A from February 1999 to June 2001, and ESD was performed in group B from July 2001 to March 2004. Group B was divided into subgroups: subgroup B-1 underwent ESD from July 2001 to March 2003 and subgroup B-2 from April 2003 to March 2004. INTERVENTIONS: All lesions were resected with conventional EMR or with ESD. MAIN OUTCOME MEASUREMENTS: En bloc resection rate, rate in completeness of resection, required time, remnant ratio, and complications were evaluated. RESULTS: With regard to lesions >10 mm in size, the en bloc resection rate and the rate in completeness of resection of group B was significantly higher than that of group A (p < 0.01). Although the required time was longer in group B than A (p < 0.01), it was shorter in subgroup B-2 compared with B-1 (p < 0.05) with lesions < or =10 mm in size. The remnant ratio and perforation rate were not different between groups. LIMITATIONS: Not applicable. CONCLUSIONS: The en bloc resection rate was better with ESD than with conventional EMR. The required time was longer in ESD, but this disadvantage might be improved with experience.     

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 submucosal dissection for residual/locally recurrent lesions after endoscopic therapy for colorectal tumors

Background and Study Aim: Residual or locally recurrent lesions may occur after endoscopic therapy for epithelial colorectal tumors. Additional endoscopic mucosal resection is difficult for large lesions. Endoscopic submucosal dissection may be useful for such lesions, but may be more technically difficult for residual/locally recurrent lesions than for primary lesions. This study evaluated the efficacy of endoscopic submucosal dissection for residual/locally recurrent lesions in comparison with primary lesions. Method: This retrospective case‐control investigated 34 residual/locally recurrent lesions and 384 primary lesions treated using endoscopic submucosal dissection. Tumor size, resected specimen size, procedure duration, en bloc resection rate, curative resection rate, histology, associated complications, and recurrence rate were compared between groups. Results: Procedure duration tended to be longer (85 ± 53 min vs 73 ± 55 min) and tumors were significantly smaller (20 ± 13 mm vs 33 ± 20 mm; P < 0.001) in the residual/locally recurrent group, compared with primary lesions. Both groups showed similar percentages of en bloc (100% vs 97.4%) and curative resection (88.4% vs. 83.6%). Perforation rate was significantly higher in the residual/locally recurrent group (14.7% vs 4.4%, P < 0.05). However, emergency surgery was only needed in 1 of 5 cases in the residual/locally recurrent group, with the remaining 4 cases conservatively managed using endoclips. Conclusions: Endoscopic submucosal dissection for residual/locally recurrent lesions was curative and efficacy. This procedure could help to avoid surgical resection and frequent follow‐up examinations in many patients.     

Outcome of endoscopic submucosal dissection for colorectal tumors in elderly people

Background

Endoscopic submucosal dissection (ESD) has been reported to be effective for the en bloc resection of large colorectal tumors. Our study investigated whether ESD was suitable for elderly people with large colorectal tumors in terms of its invasiveness.

Patients and methods

We studied 119 colorectal tumors that were treated with ESD at Kyoto Prefectural University of Medicine or Nara City Hospital between 2006 and 2009. We classified each patient as either elderly, i.e., more than 75 years old, or non-elderly, i.e., less than 75 years old. Thirty-two of the cases were classified as elderly. Performance status, tumor size, operation time, rate of en bloc resection, histopathological diagnosis, complications, and hospital stay after ESD were analyzed retrospectively in both groups.

Results

In the elderly group, the average tumor size was 32.6 mm; the average operation time, 96 min; the rate of en bloc resection, 81.2%; the rate of perforation, 3.1%; and hospital stay after ESD, 5.1 days. Histopathological diagnosis for 16 tumors was adenoma; for 13, carcinoma with invasion into the mucosa; and for three, carcinoma with invasion into the submucosa. There were no statistical differences between the two groups in any of these data. The case with perforation was treated conservatively without urgent surgery in the elderly group.

Conclusions

ESD for colorectal tumors resulted in favorable rates of en bloc resection in elderly people. Perforation occurred in elderly people, but these patients were cured with conservative treatment. ESD is a safe and minimally invasive treatment for elderly people with colorectal tumors.     

Treatment strategy for laterally spreading tumors in Japan: Before and after the introduction of endoscopic submucosal dissection

Background and Aims:  Laterally spreading tumors (LST) in the colorectum are considered good candidates for endoscopic resection (ER). Because LST-non-granular (NG) tumors show multifocal invasion into the submucosal layer, en bloc resection is necessary for adequate histopathological evaluation. Therefore, surgical resection has been recommended when a lesion is suspected to be an invasive cancer and too large to resect en bloc. The aim of the present study was to evaluate whether the introduction of colorectal ESD, which was developed for en bloc resection of early gastric cancers, could improve the en bloc resection rate of large LST-NG-type tumors and reduce the surgical resection rate.
Methods:  Between January 1999 and December 2005, a total of 166 LST-NG-type tumors measuring ≥ 20 mm in 161 patients were included in this study. The en bloc resection rate and the surgical resection rate were historically compared between two periods, before and after the introduction of ESD.
Results:  The en bloc resection rate for ER lesions was significantly higher in the latter period (35.0% [14/40] vs 76.5% [75/98]; P  < 0.001), and the rate of surgery for adenomas and intramucosal or sm minute cancers was significantly lower in the latter period (20.0% [10/50] vs 1.1% [1/89]; P  < 0.001).
Conclusions:  The introduction of colonic ESD was able to change our treatment strategy for LST, improving the en bloc resection rate and reducing the surgical resection rate.     

Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection

BACKGROUND: Repeat endoscopic mucosal resection (EMR) to cure locally recurrent early gastric cancer (EGC) is difficult to perform because the initial EMR causes submucosal fibrosis; however, ESD allows submucosal dissection through the fibrosis and provides an en bloc specimen. OBJECTIVE: The objective was to determine the safety and efficacy of ESD and compare the results to historical controls. DESIGN: This was a retrospective, case-control study. PATIENTS: We used our prospectively entered database (1993-2003) to identify 64 patients who had locally recurrent EGC after EMR. MAIN OUTCOME MEASUREMENTS: We defined the resections as curative when the lateral and vertical margins were free of cancer and repeat endoscopy showed no recurrent disease. RESULTS: Among 46 patients who underwent ESD, 41 (89.1%) en bloc resections were achieved compared to none in 18 conventional procedures (P < .0001). The specimen of 1 lesion (2.4%) out of 41 en bloc resections was histologically nonevaluable, compared with 10 lesions (43.4%) in 23 piecemeal resections (P < .0001). Three residual tumors (27.3%) were found in the 11 nonevaluable specimens. Three perforations occurred during ESD; all were successfully treated endoscopically with endoclips. LIMITATIONS: The limitation of the study was retrospective design. CONCLUSIONS: ESD provides high en bloc resection rate for locally recurrent EGC after previous EMR. In turn, en bloc resections allow precise histological staging to be assessed and prevent residual disease and recurrence.     

Beyond the snare: technically accessible large en bloc colonic resection in the West: an animal study

Background: Endoscopic submucosal dissection (ESD) and circumferential submucosal incision endoscopic mucosal resection (CSI‐EMR) are techniques for en bloc excision of large sessile colonic lesions. Our aims were to compare the efficacy, safety and learning curve of colonic hybrid knife (HK) ESD versus CSI‐EMR for en bloc excision of 50 mm diameter hemi‐circumferential artificial lesions in a porcine model. Patients and Methods: Two separate 50 mm diameter areas of normal recto‐sigmoid mucosa were marked out in each of ten pigs. One was excised with HK‐ESD using succinylated gelatin (SG) submucosal injection. The other was isolated with CSI with the Insulated Tip Knife 2 followed by SG submucosal injection then EMR with a large snare. Euthanasia and colectomy was performed at 72 h followed by blinded histopathology assessment. Results: En bloc excision rates were: HK‐ESD 100% versus CSI‐EMR 20% (P = 0.008). The mean number of resections per lesion was HK‐ESD 1 versus CSI‐EMR 3 (P = 0.001). The mean dimensions of the largest specimen per technique were HK‐ESD 63 × 54 mm versus CSI‐EMR 49 × 41 mm (P = 0.005). Procedure duration mean was HK‐ESD 54 min versus CSI‐EMR 22 min (P < 0.001). When procedure duration was adjusted for the size of the resected en bloc specimen, a statistically significant and accelerated learning effect was noted for HK‐ESD (r = ?0.83, P = 0.003). There were no perforations and no significant bleeding. Conclusions: HK‐ESD with SG submucosal injection is superior to CSI‐EMR for en bloc excision of 50 mm diameter lesions in a porcine model. The technique is rapidly learnt. This novel approach may lower the barrier to colonic ESD for Western endoscopists.