Usefulness of two-point fixed endoscopic submucosal dissection for superficial esophageal neoplasms

Background

Endoscopic submucosal dissection (ESD) is becoming widely regarded as a highly complicated but useful treatment for superficial esophageal neoplasms. However, the technique tends to be associated with adverse events. To evaluate the safety and utility of two-point fixed ESD for superficial esophageal neoplasms, and to discuss future directions.

Methods

Between December 2006 and December 2013, we performed two types of ESD procedures, the two-point fixed ESD that uses continuous countertraction to ensure a sufficient operative field was performed in 107 patients and conventional ESD was performed in 80 patients. Short-term outcomes and adverse events were evaluated. This study was retrospective study from a single institution.

Results

Significant differences were observed between conventional ESD and the two-point fixed ESD with regard to the operation time, tumor positive and unknown vertical margins of the resected specimen, perforation as an adverse event, mediastinal emphysema, and postoperative stenosis.

Conclusion

The two-point fixed ESD is a very useful method compared with the conventional procedure.

     

Usefulness of endoscopic ultrasonography in the preoperative diagnosis of submucosal digestive tumours.

INTRODUCTION: The preoperative diagnosis of submucosal lesions in the gut may be complicated. Conventional endoscopy does not allow to clearly establishing a diagnosis, and does not adequately assess lesion size. Furthermore, endoscopic biopsy is usually not diagnostic. Cytology as performed by means of fine-needle puncture does not have enough sensitivity and specificity to be considered the gold standard in the diagnosis of these lesions. We will now assess the usefulness of endoscopic ultrasonography in the study of submucosal digestive tumors. MATERIALS AND METHODS: We have prospectively collected ultrasonographic studies from all the patients with submucosal tumors who were treated surgically. We assessed the sensitivity and specificity of this technique in the diagnosis of malignancy in said lesions, alongside factors that predict malignant behavior with the highest reliability. We also valued the reliability of ultrasound endoscopy in the assessment of lesion size and the wall layer where lesions are located. The results of histological studies were considered the gold standard. RESULTS: The average size of lesions as measured by ultrasound endoscopy was 37.42 mm, with no significant differences in surgical piece: 38.98 (p = 0.143). However, conventional endoscopy underestimates the size of lesions. Endoscopic ultrasonography was able to adequately establish the origin layer of lesions in all cases. Sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound endoscopy in the diagnosis of malignancy were 89.5, 90.9, 89.5, and 90.9%, respectively. In the univariate analysis, the ultrasonographic characteristics associated with a diagnosis of malignancy included presence of ulceration (p = 0.043), size above 4 cm (p = 0.049), irregular edges of lesion (p = 0.0001), a heterogeneous ultrasonographic pattern (p = 0.002), and the presence of cystic areas above 2 mm (p = 0.012). In the multivariate analysis, the last three factors were considered independent predictive factors for malignancy. CONCLUSIONS: Endoscopic ultrasonography has a great sensitivity and specificity in the diagnosis of malignancy regarding submucosal lesions. The irregularity of lesion borders, a heterogeneous ultrasonographic pattern, and the presence of cystic areas above 2 mm in size were considered independent predictive factors for malignancy.     

Usefulness of clip traction in the early phase of esophageal endoscopic submucosal dissection

Background: The usefulness of clip traction in endoscopic submucosal dissection (ESD) for early esophageal carcinoma was investigated. Methods: A total of 87 patients who underwent ESD for esophageal squamous cell carcinoma were included in the study. The hook knife method was used for ESD. Twenty patients underwent ESD without clip traction (non‐clip group) and 67 underwent procedures in which clip traction was used (clip group). A clip with a string was attached to the oral edge of the lesion after mucosal incision in the clip group. Results: ESD was successful in all cases. Wide exposure of the submucosal tissue below the lesion was obtained by applying tension to the clip traction. The duration of ESD was shorter in the clip group, and there was a significant difference in duration between the non‐clip and clip groups. There were no complications of ESD in the clip group, but muscle layer injury occurred in three patients in the non‐clip group. Conclusion: Clip traction shortens operating time and is safer in esophageal ESD. Clip traction is recommended as a useful auxiliary procedure.     

Repeat endoscopic submucosal dissection for recurrent gastric cancers after endoscopic submucosal dissection

AIM: To clarify the safety and efficacy of repeat endoscopic submucosal dissection (re-ESD) for locally recurrent gastric cancers after ESD.METHODS: A retrospective evaluation was performed of the therapeutic efficacy, complications and follow-up results from ESD treatment for early gastric cancers in 521 consecutive patients with 616 lesions at St. Luke`s International Hospital between April 2004 and November 2012. In addition, tumor size, the size of resected specimens and the operation time were compared between re-ESD and initial ESD procedures. A flex knife was used as the primary surgical device and a hook knife was used in cases with severe fibrosis in the submucosal layer. Continuous variables were analyzed using the non-parametric Mann-Whitney U test and are expressed as medians (range). Categorical variables were analyzed using a Fisher’s exact test and are reported as proportions. Statistical significance was defined as a P-value less than 0.05.RESULTS: The number of cases in the re-ESD group and the initial ESD group were 5 and 611, respectively. The median time interval from the initial ESD to re-ESD was 14 (range, 4-44 mo). En bloc resection with free lateral and vertical margins was successfully performed in all re-ESD cases without any complications. No local or distant recurrence was observed during the median follow-up period of 48 (range, 11-56 mo). Tumor size was not significantly different between the re-ESD group and the initial ESD group (median 22 mm vs 11 mm, P = 0.09), although the size of resected specimens was significantly larger in the re-ESD group (median 47 mm vs 34 mm, P < 0.05). There was a non-significant increase observed in re-ESD operation time compared to initial ESD (median 202 min vs 67 min, respectively, P = 0.06).CONCLUSION: Despite the low patient number and short follow-up, the results suggest that re-ESD is a safe and effective endoscopic treatment for recurrent gastric cancer after ESD.     

Training in endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’ s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been pro-posed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.     

Usefulness and safety of SB knife Jr in endoscopic submucosal dissection for colorectal tumors

Use of a Dual knife has become commonplace for endoscopic submucosal dissection (ESD) of colorectal tumors at Hiroshima University Hosipital. A Hook knife has been also used in combination with the Dual knife, depending on the location of the lesion. We have had recent opportunities to use a scissors-type SB knife Jr. We retrospectively compared outcomes of colorectal ESD performed with the Dual knife in combination with the SB knife Jr versus the Hook knife. In conclusion, although the Hook knife was shown to be a very useful auxiliary device for colorectal ESD, the SB knife Jr. yielded better results than the Hook knife in terms of complete en block resection and avoidance of perforation. Use of the Dual knife with the SB Knife Jr shows good potential for improving complete en bloc resection rate and safety of technically difficult colorectal ESD.     

Usefulness of endoscopic ultrasonography in hepatology

Endoscopic ultrasonography (EUS) is used to evaluate patients with hepatobiliary diseases. The technique is useful for the diagnosis of esogastric varices in selected cases of portal hypertension, and to evaluate the pathogenic role and prognostic value of the collateral circulation in patients with this condition. When coupled with the Doppler technique, EUS can be used to guide injection sclerotherapy and to verify the obliteration of varices (particularly fundal varices) after endoscopic treatment. Hemodynamic changes induced in the collateral circulation by vasoactive drugs can also be measured with Doppler-EUS. Fine-needle aspiration under EUS guidance is useful in the diagnosis of focal liver lesions and perihepatic adenopathy, and in the evaluation of biliary tract diseases. New indications can be developed in the future after adequate experimental validation.     

Usefulness of endoscopic ultrasound for the prediction of intraoperative bleeding of endoscopic submucosal dissection for gastric neoplasms

Background and Aim: Intraoperative bleeding is an important determining factor for the technical difficulty and safety of endoscopic submucosal dissection (ESD) for gastric neoplasms, which was previously difficult to predict before ESD. In the present study, we investigated whether endoscopic ultrasound (EUS) could be used to preoperatively predict intraoperative bleeding. Methods: The study included 106 patients who underwent EUS before ESD. EUS was used to evaluate the submucosal vascular structure. Patients who had at least 10 vascular structures per field of view or a vessel at least 500 µm in diameter were classified into the rich group (Group R), and others were classified into the non‐rich group (Group N). The two groups were compared retrospectively with respect to procedure time, degree of anemia, frequency of clip use, and others. Results: There were 24 patients in Group R and 82 patients in Group N. Submucosal caner was found in 54.2% of patients in Group R and 18.3% in Group N. The reduction in hemoglobin was 5.8% in Group R and 3.45% in Group N. The procedure time was 151 min in Group R and 100 min in Group N. The frequency of clip use was 79.2% in Group R and 31.7% in Group N. A multivariate analysis revealed a significant difference in the depth of invasion and frequency of clip use between the two groups. Conclusions: The results suggest that identification of submucosal vascular structure by EUS might allow prediction of intraoperative bleeding during ESD.     

Usefulness of the clip-flap method of endoscopic submucosal dissection: A randomized controlled trial

AIM To prospectively investigate the efficacy and safety of clipflap assisted endoscopic submucosal dissection(ESD) for gastric tumors.METHODS From May 2015 to October 2016, we enrolled 104 patients with gastric cancer or adenoma scheduled for ESD at Shiga University of Medical Science Hospital. We randomized patients into two subgroups using the minimization method based on location of the tumor(upper, middle or lower third of the stomach), tumor size( 20 mm or 20 mm) and ulcer status: ESD using an endoclip(the clip-flap group) and ESD without an endoclip(the conventional group). Therapeutic efficacy(procedure time) and safety(complication: Gastrointestinal bleeding and perforation) were assessed. RESULTS En bloc resection was performed in all patients. Four patients had delayed bleeding(3.8%) and two had perforation(1.9%). No significant differences in en bloc resection rate(conventional group: 100%, clip flap group: 100%), curative endoscopic resection rate(conventional group: 90.9%, clip flap group: 89.8%, P = 0.85), procedure time(conventional group: 70.8 ± 46.2 min, clip flap group: 74.7 ± 53.3 min, P = 0.69), area of resected specimen(conventional group: 884.6 ± 792.1 mm~2, clip flap group: 1006.4 ± 1004.8 mm~2, P = 0.49), delayed bleeding rate(conventional group: 5.5%, clip flap group: 2.0%, P = 0.49), or perforation rate(conventional group: 1.8%, clip flap group: 2.0%, P = 0.93) were found between the two groups. Lessexperienced endoscopists did not show any differences in procedure time between the two groups.CONCLUSION For patients with early-stage gastric tumors, the clipflap method has no advantage in efficacy or safety compared with the conventional method.     

超声内镜结合内镜黏膜下剥离术对直肠类癌的临床疗效观察

[目的]探讨超声内镜(EUS)结合内镜黏膜下剥离术(ESD)治疗直肠类癌的效果及价值。[方法]对EUS检查发现来源于黏膜下层、无固有肌层受累、无淋巴结转移、直径≤1.5cm、考虑为直肠类癌的21例直肠黏膜隆起病灶行ESD治疗。ESD后6个月、12个月及24个月行EUS随访。[结果]21例均成功完成ESD,瘤体完整剥离,基底及边缘无残留;术中均无穿孔,术后创面少量出血5例,经内科治疗后痊愈;术后病检确诊为类癌,随访6~24个月,无一例病变残留和复发。[结论]EUS结合ESD治疗直径≤1.5cm、未侵犯固有肌层的直肠类癌安全有效,可避免不必要的外科手术。     

Balloon overtube-guided colorectal endoscopic submucosal dissection

AIM: To evaluate the usefulness of a balloon overtube to assist colorectal endoscopic submucosal dissection (ESD) using a gastroscope.METHODS: The results of 45 consecutive patients who underwent colorectal ESD were analyzed in a single tertiary endoscopy center. In preoperative evaluation of access to the lesion, difficulties were experienced in the positioning and stabilization of a gastroscope in 15 patients who were thus assigned to the balloonguided ESD group. A balloon overtube was placed with a gastroscope to provide an endoscopic channel to the lesion in cases with preoperatively identified difficulties related to accessibility. Colorectal ESD was performed following standard procedures. A submucosal fluid bleb was created with hyaluronic acid solution. A circumferential mucosal incision was made to marginate the lesion. The isolated lesion was finally excised from the deeper layers with repetitive electrosurgical dissections with needle knives. The success of colorectal ESD,procedural feasibility, and procedure-related complications were the main outcomes and measurements.RESULTS: The overall en bloc excision rate of colorectal ESD during this study at our institution was 95.6%.En bloc excision of the lesion was successfully achieved in 13 of the 15 patients (86.7%) in the balloon overtube-guided colorectal ESD group, which was comparable to the results of the standard ESD group with better accessibility to the lesion (30/30, 100%, not statistically significant).CONCLUSION: Use of a balloon overtube can improve access to the lesion and facilitate scope manipulation for colorectal ESD.     

Advanced endoscopic submucosal dissection with traction

Endoscopic submucosal dissection (ESD) has been established as a standard treatment for early stage gastric cancer (EGC) in Japan and has spread worldwide. ESD has been used not only for EGC but also for early esophageal and colonic cancers. However, ESD is as-sociated with several adverse events, such as bleeding and perforation, which requires more skill. Adequate tissue tension and clear visibility of the tissue to be dissected are important for effective and safe dissection. Many ESD methods using traction have been devel-oped, such as clip-with-line method, percutaneous trac-tion method, sinker-assisted method, magnetic anchor method, external forceps method, internal-traction method, double-channel-scope method, outerroute method, double-scope method, endoscopic-surgical-platform, and robot-assisted method. Each method has both advantages and disadvantages. Robotic endos-copy, enabling ESD with a traction method, will become more common due to advances in technology. In thenear future, simple, noninvasive, and effective ESD us-ing traction is expected to be developed and become established as a worldwide standard treatment for superficial gastrointestinal neoplasias.     

Colorectal endoscopic submucosal dissection in special locations

Colorectal endoscopic submucosal dissection(ESD) is considered one of the most challenging endoscopic procedures for novice endoscopists. When compared with the stomach, the colon and rectum have a narrower tubular lumen, greater angulation at the flexures, and a thinner muscle layer. These factors make endoscopic control and maneuverability difficult. ESD of the colorectum was considered more difficult than gastric and esophageal ESD. However, with learning from the experts, practicing, and selecting an appropriate technique,most of colorectal ESD could be performed successfully. Nevertheless, some colorectal locations are extremely specialized either from unique anatomy or given unstable scope position. Accordingly, the objective of this review was to provide endoscopists with an overview of the techniques and outcomes associated with ESD at these special colorectal locations. ESD at the discussed special locations of the ileo-colo-rectum was found to be feasible, and outcomes were comparable to those of ESD performed in non-special locations of the ileocolo-rectum. Practice for skill improvement and awareness of the unique characteristics of each special location is the key to performing successful ESD.     

内镜超声在结直肠黏膜下隆起性病变的应用分析

目的探讨超声内镜检查术（endoscopic ultrasonography,EUS）在结直肠黏膜下隆起性病变的应用价值,为临床诊疗策略提供依据。方法回顾性分析2015年10月—2019年10月天津市人民医院电子结肠镜检查发现并经EUS及手术切除后病理学确诊的229例结直肠黏膜下隆起性病变患者资料,分析病变的位置分布、种类、EUS特征及EUS初步诊断与病理诊断符合情况。结果病变部位以直肠[44.98%(103/229）]、升结肠[15.28%(35/229）]常见。病理结果显示病变以脂肪瘤最常见[34.93%（80/229）],部位以横结肠[22.50%（18/80）]、升结肠[20.00%（16/80）]为主;其次为神经内分泌瘤[33.63%（77/229）],部位以直肠[96.10%（74/77）]为主;再次为囊肿[18.78%（43/229）]。EUS下229例病变起源于黏膜下层215例,黏膜肌层11例,固有肌层3例。EUS诊断与病理结果整体诊断符合率为89.08%（204/229）,EUS诊断符合率脂肪瘤为100.00%（80/80）、气囊肿为5/5、间质瘤为3/3、神经内分泌瘤为81.82%（72/88）、囊肿为89.13%（41/46）、平滑肌瘤为1/4、淋巴管瘤为2/5,颗粒细胞瘤、神经纤维瘤均为0。结论EUS对结直肠黏膜下病变的起源层次、回声特点及病变性质等具有较准确的诊断,但对颗粒细胞瘤及神经纤维瘤等少见肿瘤的诊断具有一定局限性。     

Introduction of endoscopic submucosal dissection in the West

Endoscopic submucosal dissection (ESD) is well established in Asia as a modality for selected advanced lesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence (e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.     

Terminology for training of endoscopic submucosal dissection

Like many other advanced endoscopic skills, to master the skill of endoscopic submucosal dissection (ESD) requires training for a novice. The general medical terminology should be used similarly even in case of ESD training. However, it is not common for everyone to recall the same meaning from one medical term. Therefore, it is necessary to unify the meaning of medical terms and review their usage in a meeting to achieve a consensus. For this purpose, terms used in the upper gastrointestinal session, Endoscopic Forum Japan 2011, entitled 'Towards further penetration of ESD techniques - what is the role of Japanese ESD experts?', were determined beforehand as shown. Additionally, the present educational approach of ESD in Japan is simply outlined in this article.     

Future directions of duodenal endoscopic submucosal dissection

Endoscopic therapies for lesions of the duodenum are technically more difficult than those for lesions of the other parts of the gastrointestinal tract due to the anatomical features of the duodenum, and the incidence rate of complications such as perforation and bleeding is also higher. These aforementioned trends were especially noticeable for the case of duodenal endoscopic submucosal dissection(ESD). The indication for ESD of duodenal tumors should be determined by assessment of the histopathology, macroscopic morphology, and diameter of the tumors. The three types of candidate lesions for endoscopic therapy are adenoma, carcinoma, and neuroendocrine tumors. For applying endoscopic therapies to duodenal lesions, accurate preoperative histopathological diagnosis is necessary. The most important technical issue in duodenal ESD is the submucosal dissection process. In duodenal ESD, a short needle-type knife is suitable for the mucosal incision and submucosal dissection processes, and the Small-caliber-tip Transparent hood is an important tool. After endoscopic therapies, the wound should be closed by clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. At present, the criteria for selection between ESD and EMR vary among institutions. The indications for ESD should be carefully considered. Duodenal ESD should have limitations, such as the need for its being performed by experts with abundant experience in performing the procedure.