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.     

Histomorphologic features of early gastric carcinoma treated by endoscopic submucosal dissection: relation to efficiency of endoscopic resection

Objective: Early gastric cancer (EGC) is defined as cancer invasion confined to the mucosa or submucosa, irrespective of lymph node metastasis. Recently endoscopic submucosal dissection (ESD) has been widely accepted for the treatment for dysplasia and EGC without lymph node metastases. While the method has been advanced in Far East countries, ESD is still being developed in Europe and has not gained enough popularity although it has been recommended as the treatment of choice for superficial gastric neoplastic lesions by European Society of Gastrointestinal Endoscopy (ESGE) in 2015.

Methods: The aim of the study was to perform a retrospective analysis of clinical and histomorphologic features of 58 cases of EGCs removed by ESD in a university hospital in Western Pomerania in Poland and to evaluate factors related to the efficiency of ESD resection.

Results: With univariate analysis, indications for ESD with the highest R0 rate were found in EGCs limited to mucosa (T1a, small mucosal, M), without muscularis mucosa invasion, localised in the middle/lower part of stomach and intestinal type in histological examination. The R0 complete resection rate was significantly (p?Conclusions: Our data showed that in EGCs with favourable histomorphologic characteristics, ESD seemed to be a totally efficient and safe method of treatment in a European small-volume centre. R0 resection rate reached 81.1% of cases and median time of the ESD procedure was 61.5?min.     

The effects of oral steroid duration on stricture prevention after extensive endoscopic submucosal dissection for superficial esophageal cancer

BackgroundEsophageal stricture is a major complication of endoscopic submucosal dissection (ESD) in patients with superficial esophageal cancer (SEC). Oral steroids have been used to prevent esophageal stricture in patients with more than 75% of the esophageal circumference resected. However, there are no established guidelines regarding the optimal duration of steroid use. This retrospective observational study aimed to compare the incidence of esophageal stricture according to the period of prophylactic oral steroid use and to identify the risk factors for esophageal stricture.MethodsEighty-one patients who were prescribed prophylactic steroid after undergoing ESD for SEC with more than 75% of esophageal circumference resected were enrolled. Patients were classified into the four-week steroid group (n=72) or eight-week steroid group (n=9) to compare the incidence of esophageal stricture. In addition, the patients were subdivided into those who developed esophageal stricture (n=24) and those who did not (n=57) to identify the risk factors for esophageal stricture.ResultsTwenty patients (27.8%) in the four-week oral steroid group and four patients (44.4%) in the eight-week oral steroid group developed esophageal stricture (P=0.44). The univariable analysis identified tumor size, longitudinal length of semi-circumferential resection, and proportion of circumferential resection as risk factors of esophageal stricture. The multivariable analysis identified the proportion of circumferential resection as an independent risk factor. After adjusting for the proportion of circumferential resection, the incidence of stricture was marginally higher in the eight-week steroid group [P=0.05; odds ratio (OR): 5.69; 95% confidence interval (CI): 1.01–32.15].ConclusionsEight weeks of oral steroid prophylaxis does not reduce the risk of stricture after extensive ESD more than four weeks of oral steroid prophylaxis. The proportion of circumferential resection is the strongest risk factor for stricture in patients with SEC undergoing ESD.     

ENDOSCOPIC SUBMUCOSAL DISSECTION WITH SHEATH‐ASSISTED COUNTER TRACTION FOR EARLY GASTRIC CANCERS

Aim: Endoscopic submucosal dissection (ESD) is associated with frequent complications, such as bleeding and perforation. The procedure is technically difficult, requires considerable skill and is longer than conventional endoscopic mucosal resection (EMR). Thus, non‐invasive tools and methods are needed to facilitate direct visualization of the submucosal layer during ESD. Methods: An insulation‐tipped (IT) knife was inserted into one channel, and a conventional injection sheath was inserted to the other channel of a double‐channel fiberscope. The submucosal layer was lifted via a circumferential incision using the conventional injection sheath for visualizing cutting lines, and the submucosal layer under the lesion was directly dissected from the underlying muscularis propria. Results: Sheath‐assisted traction resulted in successful ESD with en bloc resection in all 25 patients. Hemostasis and manipulation of blood vessels were uncomplicated and dissection was completed safely, without either bleeding or perforation. The movement of the sheath was not suppressed while lifting the submucosal layer and the IT knife could be moved freely, which allowed submucosal dissection independently of the sheath movement. Conclusion: Sheath‐assisted traction ESD, using simple materials and methods, has several advantages over other standard traction methods. Our procedure is straightforward, safe, non‐invasive, cost‐effective and uses readily available instruments to enhance visualization of cutting lines.     

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.     

Primary esophageal mucosa‐associated lymphoid tissue lymphoma treated by endoscopic submucosal dissection

Primary esophageal mucosa‐associated lymphoid tissue (MALT) lymphoma is rare. There have been few reports about early primary esophageal MALT lymphoma being treated endoscopically. The clinical profile of primary esophageal MALT lymphoma is currently unclear, so it is important to accumulate more information about early esophageal MALT lymphoma. To achieve early detection of esophageal MALT lymphoma, we need more accurate knowledge and information about the macroscopic and morphological features of this tumor. Endoscopic resection is one of the most effective treatments. With respect to the lateral andvertical margins of the resected specimen, endoscopic submucosal dissection (ESD) may be superior to endoscopic mucosal resection for treating early esophageal MALT lymphoma. Here we report the macroscopic appearance of the tumor which is the first successful case of ESD for early esophageal MALT lymphoma.     

Randomized controlled trial comparing submucosal endoscopy with mucosal resection and endoscopic submucosal dissection in the esophagus and stomach: Animal study

Background and Aim

In Western countries, endoscopic submucosal dissection (ESD) has not prevailed as a result of training problems and a target patient population. We have previously reported a hybrid ESD technique, submucosal endoscopy with mucosal resection (SEMR), in which the submucosal dissection is carried out chiefly by blunt balloon dissection. We have also reported successful application in the porcine colon. In the present study, we compared the safety and efficacy of SEMR with ESD in the porcine esophagus and stomach.

Methods

SEMR and ESD were carried out in eight domestic pigs under general anesthesia. Resection sites were marked by circumferential coagulation. After circumferential ESD knife mucosal incision, submucosal fluid cushion (SFC) was created. In the SEMR group, the balloon catheter was inserted deep into the SFC. The balloon was then inflated and pulled back toward the endoscope tip repeatedly, altering the direction, to disrupt the submucosa. Residual strands were cut with an IT‐knife. En bloc resection rates, procedure times, complications and dissection difficulty scales (DDS) were recorded prospectively. DDS were rated using a visual analog scale.

Results

Thirty‐two resections (8 SEMR/8 ESD in the esophagus; 8 SEMR/8 ESD in the stomach) were done with no major adverse events. There was no statistical difference between the two techniques in either location in the above categories measured.

Conclusions

SEMR and traditional ESD are comparable techniques in safety and effectiveness when carried out in the esophagus and stomach. SEMR may serve as a more appealing technical option for endoscopists who are unable to sustain a traditional ESD practice volume.     

A novel endoscopic submucosal dissection technique for proton pump inhibitor-refractory gastroesophageal reflux disease

Abstract

Objectives: Although drug treatment is the usual first-line therapy for gastroesophageal reflux disease (GERD), not all patients receive satisfactory relief from drug therapy, alone. We developed an endoscopic fundoplication technique using endoscopic submucosal dissection (ESD); the technique is referred to as ESD for GERD (ESD-G). This study investigated the safety and efficacy of this novel technique in patients with drug-refractory GERD. Patients and methods: ESD-G narrows the hiatal opening through ESD of the esophagogastric junction (EGJ) mucosa. For safety reasons, the range of mucosal resection was limited to half (1/2 or 1/4 +1/4) of the circumference of the EGJ lumen. ESD-G was performed on 13 patients with proton pump inhibitor (PPI)-refractory GERD. GERD symptoms, PPI dose, and 24-h esophageal pH monitoring results were compared before and 6 months after the procedure. Results. In 12 cases, symptoms significantly improved after ESD-G. Five patients demonstrated improved esophagitis, three were able to discontinue PPI therapy, and three were able to reduce their PPI dosage following surgery. The esophageal pH <4 holding time ratio was also decreased after ESD-G. Conclusions. ESD-G may be useful for PPI-refractory GERD patients.     

CARBON DIOXIDE SUBMUCOSAL INJECTION CUSHION: AN INNOVATIVE TECHNIQUE IN ENDOSCOPIC SUBMUCOSAL DISSECTION

Aim: Endoscopic submucosal dissection (ESD) can successfully resect large lesions en bloc, but it requires a satisfactory submucosal (sm) injection agent for proper safety and efficacy. The aim of the present study was to evaluate the effectiveness of carbon dioxide (CO₂) as an ESD sm injection agent. Methods: In vitro study using porcine stomachs compared CO₂ with normal saline (NS) and sodium hyaluronic acid (SHA) solution, both of which are currently used to provide long‐lasting sm elevation during ESD. Histopathological examination assessed differences between CO₂ and NS sm cushions. ESD were then carried out in vivo in the stomach and rectum of a live pig using CO₂ sm injection. Results: CO₂ sm elevation was significantly longer lasting than either NS or SHA (P < 0.001). Histopathology revealed no mucosal layer tissue damage, and dissection of honeycomb‐like fibrous connective tissue in the CO₂ sm cushion. Creating and maintaining a CO₂ sm cushion of sufficient elevation combined with partial physical dissection of the sm layer was achieved, followed by complete endoscopic dissection of the sm layer with all ESD, resulting in successful en‐bloc resections having a mean specimen size of 24.3 mm within 15 min. Conclusion: Safety and efficacy of CO₂ as a satisfactory sm injection agent during ESD was successfully demonstrated in these preliminary studies, warranting further investigation of this innovative technique.     

Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions

Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.     

Efficacy of traction‐assisted colorectal endoscopic submucosal dissection using a clip‐and‐thread technique: A prospective randomized study

Background and Aim

Colorectal endoscopic submucosal dissection (ESD) remains challenging because of technical difficulties, long procedure time, and high risk of adverse events. To facilitate colorectal ESD, we developed traction‐assisted colorectal ESD using a clip and thread (TAC‐ESD) and conducted a randomized controlled trial to evaluate its efficacy.

Methods

Patients with superficial colorectal neoplasms (SCN) ≥20 mm were enrolled and randomly assigned to the conventional‐ESD group or to the TAC‐ESD group. SCN ≤50 mm were treated by two intermediates, and SCN >50 mm were treated by two experts. Primary endpoint was procedure time. Secondary endpoints were TAC‐ESD success rate (sustained application of the clip and thread until the end of the procedure), self‐completion rate by the intermediates, and adverse events.

Results

Altogether, 42 SCN were analyzed in each ESD group (conventional and TAC). Procedure time (median [range]) for the TAC‐ESD group was significantly shorter than that for the conventional‐ESD group (40 [11–86] min vs 70 [30–180] min, respectively; P < 0.0001). Success rate of TAC‐ESD was 95% (40/42). The intermediates’ self‐completion rate was significantly higher for the TAC‐ESD group than for the conventional‐ESD group (100% [39/39] vs 90% [36/40], respectively; P = 0.04). Adverse events included one intraoperative perforation in the conventional‐ESD group and one delayed perforation in the TAC‐ESD group.

Conclusion

Traction‐assisted colorectal endoscopic submucosal dissection reduced the procedure time and increased the self‐completion rate by the intermediates (UMIN000018612).     

Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection(ESD) have been developed. Clip-with-line(CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial(CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD(CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed th...     

FACTORS RELATED TO LATERAL MARGIN POSITIVITY FOR CANCER IN GASTRIC SPECIMENS OF ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: With the widespread use of endoscopic submucosal dissection (ESD), more large early gastric cancers (EGC) have become candidates for endoscopic resection. A precise diagnosis of the extent of cancer is indispensable to obtain R0 resection. The aim of the present study was to clarify the factors related to lateral margin positivity for cancer in specimens resected by ESD for EGC. Methods: Among 1549 EGC treated by ESD during September 2002 to December 2008, lesions that were resected in an en‐bloc fashion and resulted in a pathological diagnosis of lateral margin positive (LM+) for cancer, were extracted. The reason for LM+ and pathological characteristics of the lesions were studied and compared to lesions successfully resected with margins negative for cancer. Results: There were three types of lesion that resulted in LM+ resection: lesions with a flat spreading area, lesions with an unexpected nearby lesion, and lesions with lateral extension beneath a non‐cancerous mucosa. Compared to lesions resected with margins negative for cancer, diameter of the tumor, recurrent‐type cancer, submucosal cancer, and undifferentiated‐type cancer were factors significantly related to LM+ resection. Conclusion: Other than misdiagnosing a small portion of cancer extension, lateral margin positivity for cancer by ESD could result from a neighboring lesion and an unexpected lateral submucosal cancer extension. To avoid LM+ resection of EGC by ESD, one should be careful of unexpected lateral extension and simultaneous multi‐lesions.     

EN BLOC REMOVAL OF A GASTRIC CARCINOID TUMOR USING ENDOSCOPIC SUBMUCOSAL DISSECTION TECHNIQUES

Endoscopic submucosal dissection (ESD) has recently been applied to the resection of gastric submucosal tumors other than carcinoid tumors. We describe a case of gastric carcinoid tumor enucleated with ESD. An 82‐year‐old woman was referred for treatment of a gastric tumor. Upper gastrointestinal endoscopy revealed a solitary submucosal tumor in the greater curvature of the gastric body. We diagnosed a carcinoid tumor by histological examination of biopsy specimens. Endoscopic ultrasound revealed a hypoechoic mass in the submucosal layer. Neither lymph node nor liver metastasis was recognized. The serum gastrin level was normal, and this tumor was classified as a type III (sporadic) carcinoid tumor. Endoscopic resection was decided on considering her age, general status, and wishes. We used ESD techniques, because the tumor was too large to be resected by conventional endoscopic mucosal resection. En bloc resection was performed. Histological examination of the 13 × 19 × 11 mm resected specimen showed that the cut end was free of tumor cells. Type III carcinoid tumor is usually treated by surgical resection with lymph node dissection. However, in high‐risk elderly patients we consider ESD to be a therapeutic option for local control of gastric carcinoid tumors.     

Influential factors in procedure time of endoscopic submucosal dissection for gastric cancer with fibrotic change

Background: Factors correlating with the technical difficulty of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) are still unclear. EGC coexisting with fibrosis inside lesions has been a common therapeutic indication for ESD. The aim of this study was to clarify the most important factor related to difficult ESD for EGC. Patients and Methods: Fifty‐six patients (49 male and seven female, median age 66 years) who received ESD at a single institute for EGC with fibrosis in the resected lesion were selected. Various clinicopathological factors, including the histological findings of fibrotic changes within the cancer area in the resected specimen, were evaluated statistically for correlation with ESD procedure time. Results: Univariate linear regression analysis with logarithmic ESD procedure time revealed the upper‐third portion of lesion in the stomach (P = 0.02), histological classification of dense fibrosis (ulcer/ulcer scar‐III/IV) within EGC (P < 0.001), and presence of peptic ulcer other than EGC (P = 0.04). Areas of the resected specimen (P < 0.001) and fibrosis (P < 0.001) were significant factors related to prolonged operation times. Multivariate analysis demonstrated that the upper‐third portion of lesion (P = 0.007), ulcer/ulcer scar‐III/IV findings (P = 0.006), and area of resected specimen (P = 0.006) were significant independent factors influencing ESD procedure time. Conclusion: Histological findings of fibrotic changes coexisting with EGC are closely related to technical difficulty in ESD as well as the location of tumors. Preoperative precise evaluation of fibrotic changes within EGC may be helpful to predict a technical difficulty in ESD.     

Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos)

BACKGROUND: Endoscopic submucosal dissection (ESD) enables direct submucosal dissection so even large early stage GI tumors can be resected en bloc. Colorectal ESD is technically more difficult, however, and there is an increased risk of complications such as perforation and bleeding compared with gastric ESD. As a result, further refinements are required in this procedure. OBJECTIVE: Our purpose was to evaluate thin endoscope-assisted (TEA) ESD, a new traction system for improving submucosal cutting line visualization. DESIGN: Case series. SETTING: Okayama University Hospital. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of the TEA-ESD procedure. RESULTS: Three cases of large, flat, elevated colorectal tumors (laterally spreading tumors) in the rectum and rectosigmoid colon were safely and successfully removed en bloc without complications. Total procedure times were 3 hours, 40 minutes, and 30 minutes with resected specimens measuring 70 x 68 mm, 38 x 35 mm, and 30 x 20 mm, respectively. LIMITATIONS: TEA-ESD was performed in only the rectum and rectosigmoid colon. CONCLUSIONS: This limited case series demonstrated that large laterally spreading tumors in the rectum and rectosigmoid colon could be safely resected en bloc with TEA-ESD.     

Influence of endoscopic submucosal dissection on serum levels of pepsinogens in patients with early gastric cancer

Background: The serum levels of pepsinogens (PG) have been considered to be a useful marker for assessing the risk of metachronous gastric cancer in patients who undergo endoscopic submucosal dissection. However, the influence of endoscopic submucosal dissection (ESD) on serum levels of PG has not yet been examined. The aim of this study was to examine whether the level of PG after ESD can be used to predict the risk of metachronous cancer. Patients and Methods: The study included of 100 consecutive patients who underwent ESD for gastric cancer at Hirosaki University Hospital from September 2009 to February 2011. Serum levels of PG I and II on the day before and after ESD were compared. Stool antigen test was also performed to examine the presence of Helicobacter pylori infection. Results: The mean serum level of PG I before and after ESD was 34.3 ± 31.6 ng/mL and 70.5 ± 100.0 ng/mL (P < 0.001), respectively. PG I/II ratio before and after ESD was 2.40 ± 1.51 and 2.79 ± 1.70 (P < 0.001). The serum level of PG I and the PG I/II ratio were significantly changed after ESD, regardless of the use of proton pump inhibitor, Helicobacter pylori infection or the location of the tumor. Conclusions: ESD treatment modulates the serum level of PG I and significantly increases the PG I/II ratio. Serum levels of PG should be measured before the ESD procedure is performed to predict the risk of developing metachronous gastric cancer after ESD.     

H. pylori negative gastric MALT lymphoma with API2-MALT1 translocation treated by endoscopic submucosal dissection: A case report

Rationale:API2-MALT1 positive gastric mucosa-associated lymphoid tissue (MALT) lymphomas are considered to have favorable prognosis. We report a case of API2-MALT1 positive gastric MALT lymphoma, treated by endoscopic submucosal dissection (ESD).Patient concerns:A 51-year-old man underwent esophagogastroduodenoscopy (EGD) for the annual health checkup examination.Diagnoses:The EGD showed a reddish depressed lesion with small reddish spots in the lower gastric body. There was no endoscopic atrophy in the entire stomach and Helicobacter pylori (H. pylori) serum test was negative. Infiltration of small lymphocytes was shown in the gastric tissues obtained by the endoscopic biopsy. The fluorescence in situ hybridization using the biopsy samples confirmed the presence of genetic translocation of API2-MALT1, suggesting that the lesion is API2-MALT1 positive MALT lymphoma.Interventions:Since endoscopic ultrasound suggested that the lesion was localized within the lamina propria mucosae, we performed ESD to achieve the en bloc resection of the lesion.Outcomes:Conclusive diagnosis of gastric MALT lymphoma was made based on the resected specimen. Lateral and vertical margins were negative. No lymphoma cells were detected using endoscopic biopsy after 5 years.Lessons:Our report suggests that ESD can be considered as alternative treatment for API2-MALT1 positive gastric MALT lymphoma if the lesion was localized within the gastric mucosa.     

ENDOSCOPIC SUBMUCOSAL DISSECTION (TWO‐POINT FIXED ESD) FOR EARLY ESOPHAGEAL CANCER

Background: We have been attempting to improve the safety, reliability and simplicity of endoscopic submucosal dissection for the treatment of early esophageal cancer and to shorten the time needed for this operation. Methods: The present study involved nine patients with well‐differentiated intramucosal early esophageal cancer over 20 mm in diameter. Two‐point fixed endoscopic submucosal dissection was carried out. Results: In all nine cases, the mucosal area to be dissected was successfully identified and kept under direct vision, allowing two‐point fixation of the mucosa with forceps and the hood during adequate counter‐traction. In this way, the respiration‐caused movement of submucosal tissue between the two fixing points was suppressed almost completely. Hemostasis and manipulation on blood vessels were easy with this procedure and dissection could be completed safely, without causing perforation. Conclusion: Endoscopic submucosal dissection with a transparent hood fitted with a mucosa‐holding forceps channel is highly useful, safe and simple when applied to the esophagus.     

Optimal injection solution for endoscopic submucosal dissection: A randomized controlled trial of Western solutions in a porcine model

Background and Aim

When carrying out endoscopic submucosal dissection (ESD), procedural safety increases with greater tissue elevation and efficiency increases with longer‐lasting submucosal cushion. Fluids specifically developed for ESD in Asia are not commercially available in the West, leaving endoscopists to use a variety of injectable fluids off‐label. To determine the optimal fluid available in the West, we compared commonly used fluids for Western ESD.

Methods

All phases were carried out in an ex vivo porcine stomach model. Phase 1 compared tissue elevation and duration of submucosal cushions produced by various standard volumes of various injectable solutions used for ESD. The two best‐performing solutions used off‐label were tested head‐to‐head in ESD in Phase 2. Phase 3 compared the best solution from Phase 2 to Eleview^®, currently the only submucosal injection fluid approved in the USA. In Phases 2 and 3, five ESD were carried out with each solution. The solutions were randomized and the endoscopist blinded to the solution.

Results

The best‐performing solutions in Phase 1 were 0.4% hyaluronic acid, 6% hydroxyethyl starch (HES), and Eleview^®. Phase 2 compared 6% HES and hydroxypropyl methylcellulose (HPMC), showing that ESD with 6% HES was easier (P = 0.007), faster (P = 0.041) and required less injection volume (P = 0.003). In Phase 3, resection speed, ease of ESD and total volume per area resected were comparable between 6% HES and Eleview^®.

Conclusions

Of the submucosal injection fluids currently available in the West, Eleview^® and 6% HES are the best‐performing solutions for ESD in a porcine model.