Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions

Factors Predictive of Complete Excision of Large Colorectal Neoplasia Using Hybrid Endoscopic Submucosal Dissection: A KASID Multicenter Study

BACKGROUND

Endoscopic submucosal dissection (ESD) with snaring (hybrid ESD) bridges the gap between ESD and endoscopic mucosal resection. We evaluated factors predictive of en bloc and complete resection of large colorectal neoplasms using hybrid ESD.

METHODS

This was a prospective clinical study of 78 patients who underwent hybrid ESD for excision of colorectal neoplasms (≥ 2 cm) between May 2015 and September 2016 at six university hospitals. We evaluated lesion and patient characteristics, endoscopist experience level (< 50 or ≥ 50 cases with colorectal ESD), and technical factors such as concurrent fibrosis, completion of a circumferential incision, degree of submucosal dissection (< 50 or ≥ 50%), and visualization during snaring (< 50 or ≥ 50%).

RESULTS

Multivariate analyses showed that the en bloc resection rate was significantly related to the degree of visualization during snaring (odds ratio (OR) 7.811, 95% confidence interval [CI] 1.722-35.426; p = 0.008) and the presence of fibrosis (OR 0.258, 95% CI 0.68-0.993; p = 0.049). The complete resection rate was significantly related to the colorectal ESD endoscopist skill level (OR 5.626, 95% CI 1.485-21.313; p = 0.011) and gross lesion type (OR 0.145, 95% CI 0.022-0.936; p = 0.042). When all three technical factors, i.e., completion of circumferential incision, ≥ 50% submucosal dissection, and ≥ 50% visualization during snaring, were satisfied performing hybrid ESD, the en bloc resection rate (87.5%) was similar to that of ESD.

CONCLUSIONS

Visualization during snaring, presence of fibrosis, gross lesion type, and endoscopist colorectal ESD experience level affect en bloc or complete resection of large colorectal neoplasia using hybrid ESD.

Interaction between Medical Treatment and Minimally Invasive Surgical Treatment for the Malignancies of the Digestive Tract

Recently, endoscopic diagnosis and treatment methods for early cancer in the digestive tract have made rapid progress. As for surgery, laparoscopic and thoracoscopic techniques have achieved rapidly advancing development in the last 2 decades. Early detection of the malignant lesion and the evolution of endoscopic and surgical device enabled in performing the minimally invasive surgery. Collaboration of medical treatment and minimally invasive surgery for advanced cancer is ongoing in the case of some conditions and in a few institutes. In this review, the contents of the core symposia on "Interaction between medical treatment and minimally invasive surgical treatment for the malignancies of the digestive tract", held at the 11, 12 and 13th annual meeting of the Japanese Gastroenterological Association, are summarized. At each annual meeting, the core symposium focused primarily on gastric, colorectal, and esophageal cancer treatment. For gastric cancer, endoscopic resection and laparoscopic surgery were 2 important key words. For colorectal cancer, multidisciplinary therapy was a major key word. And for esophageal cancer, endoscopic resection, chemoradiotherapy, thoracoscopic surgery and salvage surgery were key words. Patients' survival and quality of life are expected to further advance as a result of the collaboration of such therapeutic modalities.

[Endoscopic and surgical treatment of early gastric and esophageal carcinoma]

BACKGROUND

The treatment of early gastric (EGC) and esophageal carcinomas (EEC) is an interdisciplinary challenge. The risk of lymph node metastasis (LNM) is the crucial point in choosing the correct treatment option.

OBJECTIVE

This article gives an overview of the current treatment options and provides help in choosing the correct therapy.

METHOD

Current concepts and therapy algorithms are presented on the basis of a literature review and data from our own center.

RESULTS

Endoscopic submucosal dissection (ESD) is recommended for mucosal gastric cancer with good or moderate differentiation (G1,2) without macroscopic ulceration, in elevated type lesions smaller than 2 cm in size or depressed lesions smaller than 1 cm in size. In additional chromoendoscopy should be carried out. The extent of surgical resection is defined by the location of the tumor. A safety margin of at least 3 cm should be applied in distal gastric resections whereas the first line goal in gastrectomy is to achieve an R0 resection. In cN0 tumors a D1 lymphadenectomy (LA) seems to be sufficient. Minimally invasive techniques currently show promising results especially for a subtotal resection. The treatment strategy in EEC differs depending on the tumor entity. Mucosal squamous cell carcinoma with high risk factors (L1,V1) and all cN0 submucosal tumors without the detection of LNM should be referred to primary surgical resection. Early stage cN+ squamous cell carcinomas should be preoperatively treated with chemoradiotherapy. Adenocarcinoma with infiltration of the deeper submucosa (sm2,3) and high-risk sm1 tumors require surgical treatment. The standard operating procedure for EEC is an Ivor Lewis esophagectomy with 2‑field LA preferably performed as a hybrid or by a completely minimally invasive procedure. The procedure of choice in endoscopic resection of EEC is resection with the suck and cut technique.

[Endoscopic Treatment of Gastric Adenoma]

Gastric adenoma (dysplasia) is a precancerous lesion. Therefore, managements of gastric adenomas are important for preventing the development of gastric cancers and for detecting gastric cancers at earlier stages. The Vienna classification divides gastric adenomas into two categories: high-grade dysplasia and low-grade dysplasia. Generally, endoscopic resection is performed for adenoma with high-grade dysplasia due to the coexistence of carcinoma and the potential of progression to carcinomas. However, the treatments of adenoma with low-grade dysplasia remain controversial. Currently two treatment strategies for the low-grade type have been suggested; First is the 'wait and see' strategy; Second is endoscopic treatment (e.g., endoscopic mucosal resection, endoscopic submucosal dissection, or argon plasma coagulation). In this review, we discuss the current optimal strategies for endoscopic management of gastric adenoma.

CHARACTERIZATION OF THE MUCIN PHENOTYPE CAN PREDICT GASTRIC CANCER RECURRENCE AFTER ENDOSCOPIC MUCOSAL RESECTION

BACKGROUND

Endoscopic mucosal resection is still considered an accepted treatment for early gastric cancer for selected cases. Histopathologic criteria for curative endoscopic resection are intramucosal well-differentiated adenocarcinoma, lateral and deep margins free of tumor, no histological ulceration, and no venous or lymphatic embolism. A 5% local recurrence rate has been described even when all the above-mentioned criteria are met. On the other hand, antigen expression by tumoral cells has been related to the biological behavior of several tumors.

OBJECTIVE

To evaluate whether early gastric cancer mucin immunoexpression, p53 and Ki-67, can predict recurrence after endoscopic mucosal resection, even when standard histopathologic criteria for curative measures have been attempted.

METHODS

Twenty-two patients with early gastric cancer were considered to have been completely resected by endoscopic mucosal resection. Local recurrence occurred in 5/22 (22.7%). Immunohistochemical study was possible in 18 (81.8%) resected specimens. Patients were divided in two groups: those with and those without local recurrence. They were compared across demographic, endoscopic, histologic data, and immunohistochemical factors for MUC2, MUC5a, CD10, p53, and Ki-67.

RESULTS

Mucin immunoexpression allowed a reclassification of gastric adenocarcinoma in intestinal (10), gastric (2), mixed (4), and null phenotypes (2). Mixed phenotype (positive for both MUC2 and MUC5a) was found in 80% of cases in the local recurrence group, while the intestinal type (positive MUC2 and negative MUC5a) was found in 76.9% of cases without local recurrence (P=0.004). Other observed features did not correlate with neoplastic recurrence.

CONCLUSION

The mixed phenotype of early gastric adenocarcinoma is associated with a higher probability of local recurrence after endoscopic mucosal resection.

Colorectal endoscopic mucosal resection (EMR)

Colonoscopy has the benefit of detecting and treating precancerous adenomatous polyps and thus reduces mortality associated with CRC. Screening colonoscopy is the keystone for prevention of colorectal cancer. Over the last 20 years there has been increased in the management of large colorectal polyps from surgery to endoscopic removal techniques which is less invasive. Traditionally surgical resection was the treatment of choice for many years for larger polyps but colectomy poses significant morbidity of 14-46% and mortality of up to 7%. There are several advantages of endoscopic resection technique over surgery; it is less invasive, less expensive, has rapid recovery, and preserves the normal gut functions. In addition patient satisfaction and efficacy of EMR is higher with minor complications. Thus, this has facilitated the development of advanced resection technique for the treatment of large colorectal polyps called as endoscopic mucosal resection (EMR).

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.

Comparative evaluation of colonoscopy-assisted transanal minimally invasive surgery via glove port and endoscopic submucosal dissection for early rectal tumor

BACKGROUND

Early rectal tumor is usually managed by local excision. A novel method-colonoscopy-assisted transanal minimally invasive surgery via glove port (CA-TAMIS-GP)-for resecting early rectal tumor was developed and compared with endoscopic submucosal dissection (ESD).

MATERIALS AND METHODS

We performed CA-TAMIS-GP surgery on 26 patients from January 2014 to February 2016. For better analysis, we retrospectively collected data from 31 patients who underwent ESD between October 2012 and December 2013; overall, 57 patients diagnosed with early rectal tumor were included in this study. Perioperative conditions and long-term outcomes of both groups were compared.

RESULTS

All lesions were dissected completely and successfully without conversion to open surgery or major complications. On histopathologic examination, all specimens in this study had negative margins. All patients had uneventful postoperative recoveries, except 3 patients of CA-TAMIS-GP with minor hematochezia, which resolved spontaneously; 7 ESD patients had late-onset bleeding and 3 needed colonoscopic hemostasis; 2 patients in each group had mild fever. The CA-TAMIS-GP group had a shorter operation time, less hemorrhage, and a lower average consumable cost than the ESD group (P < 0.05); moreover, the CA-TAMIS-GP group had no recurrence or long-term complications during a follow-up of 10-32 months, whereas3 patients in the ESD group developed local recurrence during a follow-up of 24-36 months.

CONCLUSIONS

The CA-TAMIS-GP is a new method that is safe and effective in patients with early rectal tumor and appears to have a shorter operation time and less blood loss as compared with ESD.

Endoscopic Management of Early Esophagogastric Cancer

Esophagogastric cancer accounts for the second most common cause of cancer-related mortality worldwide. Significant efforts have been made to detect these malignancies at an earlier stage through the implementation of screening programs in high-risk individuals using advanced diagnostic techniques. Endoscopic management techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have consistently demonstrated excellent outcomes in the management of these lesions. These techniques are associated with a lower risk of morbidity and mortality when compared with traditional surgical management.

Efficacy of double-scope endoscopic submucosal dissection and long-term outcomes of endoscopic resection for superficial pharyngeal cancer

BACKGROUND AND AIM

Owing to increased awareness and use of narrow-band imaging, there are more opportunities to treat superficial pharyngeal cancer (SPC). The present study aimed to describe the short- and long-term outcomes of endoscopic resection (ER) for SPC.

METHODS

This study included 166 consecutive SPC in 113 patients treated during 2006 to 2013 at one referral cancer center. In the first period, we treated patients using endoscopic mucosal resection (EMR), in the second period using conventional ESD (cESD) and in the recent period using double-scope ESD (dsESD), which involves a second thin endoscope for assistance to produce traction. Median follow-up period was 30 months.

RESULTS

All lesions were diagnosed as squamous cell carcinoma. Complete resection rate of cESD and dsESD procedures was 56.4% and 82.3% (P < 0.01), and local recurrence rate was 2.6% and 0.0%, respectively. Procedure duration was significantly shorter for dsESD than for cESD (P < 0.05). Four cases of recurrent lymph node (LN) metastasis were observed; however, all patients with LN metastases survived to a 48-month median interval after neck dissection. Risk factors for LN metastasis included subepithelium invasion, tumor thickness >1000 μm, droplet infiltration, and lymphovascular invasion. Overall survival rate after 5 years was 79.5%; no patients died of SPC. Cumulative rate of metachronous SPC after 5 years was 46.5%.

CONCLUSION

ER for SPC is a feasible and effective treatment, although metachronous SPC occurred frequently. For the technique of ER, dsESD was effective.

Successful hemostasis and resection of a bleeding gastric polyp by endoscopic banding ligation in a uremic patient taking antiplatelet agent

The modalities to treat bleeding polyps include electrocautery snare polypectomy, adrenaline injection, clipping, argon plasma coagulation and surgery. We hereby describe an endoscopic banding ligation method for the management of bleeding gastric polyp in a patient receiving antiplatelet therapy. A 66-year-old man presented with a five month-history of intermittent tarry stool passage, nausea and fatigue. He had a past history of peripheral arterial occlusive disease and non-insulin dependent diabetes mellitus with end stage renal disease, and regularly took antiplatelet agent (ticlopidine 100 mg thrice daily) for cardiovascular prophylaxis. On examination, the patient was grossly pale, ill in appearance, with a pulse of 110/min and blood pressure of 108/76 mmHg. Laboratory examination revealed hemoglobin of 7.8 g/dl. Endoscopic examination revealed a bleeding sessile polyp over the posterior wall of the antrum. Endoscopic banding ligation was carried out by a pneumoactivated esophageal variceal ligation device set. Bleeding stopped immediately following the procedure, and the patient recovered uneventfully. It is suggested that endoscopic banding ligation is a safe and effective technique for the treatment of bleeding gastrointestinal polyps in patients receiving antiplatelet therapy.

Endoluminal Instrumentation Is Changing Gastrointestinal Surgery

Advances in endoluminal instrumentation and technology are enabling endoscopists to perform increasingly sophisticated procedures. Indications for these procedures are likely to expand as outcomes studies show they are efficacious and cost-effective. This article highlights several recent advances in endoluminal suturing, dissecting, and ligating and discusses the impact of these advances on the practice of gastrointestinal surgery. Endoluminal suturing offers select patients with gastroesophageal reflux disease a safe and effective alternative to laparoscopic surgery. Devices designed for endoluminal hemostasis and endoscopic mucosal resection can be used effectively for a broader range of applications and are already being used to perform transluminal surgery in animal models; human trials are forthcoming. Gastrointestinal surgeons should support efforts to critically evaluate endoluminal techniques because they have an opportunity to improve care. Surgical residents planning careers in gastrointestinal surgery need to understand endoscopic techniques and consider their training opportunities.

Endoscopic Resection and Radiofrequency Ablation for Early Esophageal Neoplasia

In the last few decades, endoscopic treatment of early neoplastic lesions in the esophagus has established itself as a valid and less invasive alternative to surgical resection. Endoscopic resection (ER) is the cornerstone of endoscopic therapy. Next to the curative potential of ER, by removing neoplastic lesions, ER may also serve as a diagnostic tool. The relatively large tissue specimens obtained with ER enable accurate histological staging of a lesion, allowing for optimal decision-making for further patient management. ER was pioneered in Japan, mainly for the resection of gastric lesions and squamous esophageal neoplasia, and also Western countries have been increasingly implementing ER in the treatment of early gastroesophageal neoplasia, mostly associated with Barrett's esophagus (BE). In BE, however, there is still a risk of metachronous lesions in the remainder of the Barrett's after focal ER. Additional treatment of all Barrett's mucosa is therefore advised. Currently, the most effective method for this is by using radiofrequency ablation (RFA). This review will provide an overview of indications for ER and RFA. Key Messages and Conclusions: Endoscopic management of early esophageal neoplasia is a safe and valid alternative to surgery and is nowadays the treatment of choice. ER is the mainstay of endoscopic management of early esophageal neoplasia since it allows for removal of neoplastic lesions and provides a large tissue specimen for histological evaluation. In case of early neoplasia in BE, focal ER should be complemented by eradication of the remaining Barrett's mucosa. RFA has proven to be a safe and effective modality to achieve complete eradication of Barrett's mucosa.

Endoscopic resection of early gastric cancer: current status and new approaches

Endoscopic resection (ER) of early gastric cancer (EGC) has been an optimal treatment for selected patients. As endoscopic submucosal dissection (ESD) has been widely used for treatment of EGC, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis (LNM). Moreover, a new microscopic imaging for precise endoscopic diagnosis of EGC is introduced. This review covers the current status and new approaches of ER of EGC.

Endoscopic Full-thickness Resection (EFTR) for Gastrointestinal Subepithelial Tumors

There has been booming interest in the endoscopic full-thickness resection (EFTR) technique since it was first described. With the advent of improved and more secure endoscopic closure techniques and devices, such as endoscopic suturing devices, endoscopists are empowered to perform more aggressive procedures than ever. This article focuses on the procedural technique and clinical outcomes of EFTR for gastrointestinal subepithelial tumors.

Detection and Management of Early Gastric Cancer

OPINION STATEMENT

Early gastric cancer (EGC), defined as being confined to the submucosa, is a curable condition. In recent years, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely applied to subgroups of mucosal cancers, thereby avoiding the burden of operation while preserving gastric function. However, it can be difficult to identify mucosal cancers, which often evade detection due to their flat shapes without ulceration. Proper preparation to clean the mucosal surface, detailed systematic observation of the entire stomach, and the use of high-resolution systems for both endoscopies equipped with image-enhanced modality and monitors would facilitate the detection of such lesions. It is also critical to evaluate the resected specimen to confirm completeness of resection (tumor-free lateral and vertical margins as well as the absence of lymphatic and vascular invasion). If the resection is incomplete, further treatment is usually recommended-further endoscopic resection for patients with positive lateral margins or surgery for patients with positive vertical margins or with lymphatic or vascular involvement. The five-year survival for endoscopically resected EGC is excellent-and comparable to that of surgical therapy. Since most gastric cancers are caused by Helicobacter pylori, this infection should be tested for routinely. If a patient is H. pylori-positive, eradication is recommended, as heterotopic, metachronous recurrence of EGC is subsequently reduced. Importantly, basic principles for early diagnosis and endoscopic treatment of EGC can be applied to neoplasms arising in other parts of the gut, such as the esophagus and colon, and would be beneficial for patients through preserving organ function and minimizing operative intervention.

Cap-assisted Endoscopic Mucosal Resection is Highly Effective for Nonpedunculated Colorectal Lesions

GOALS

To assess the safety and efficacy of cap-assisted endoscopic mucosal resection (C-EMR) for nonpedunculated colorectal lesions.

BACKGROUND

There are little data supporting the safety and efficacy of C-EMR for colorectal polyps.

STUDY

A retrospective review was conducted on the medical records of 97 consecutive patients who underwent C-EMR for nonpedunculated colorectal lesions in a tertiary center by a single gastroenterologist (L.H.J.). Reported outcomes were: overall eradication rate that included all attempted C-EMRs, endoscopist-reported eradication rate that included C-EMRs reported as a success, and complications rate.

RESULTS

A total of 134 C-EMRs were performed on 124 nonpedunculated colorectal lesions within a 55-month period, with a median follow-up of 4.2 (1.6 to 46.8) months. Among the polyps with available follow-up, the overall eradication rate was 91% (81/89); the endoscopist-reported eradication rate was 98.8% (81/82). The complications rate was 10.2%: perforation (3.9%), intraprocedural bleeding (3.9%), and delayed bleeding (2.4%); all but 2 perforation cases that required surgical interventions (both occurring early in the time period in which procedures were performed), were treated endoscopically or conservatively with complete recovery.

CONCLUSIONS

C-EMR is highly effective in treating nonpedunculated colorectal lesions, which can be learned and practiced in the appropriate setting. Decline in the complications rate was observed as the endoscopist gained experience. Although perforation remains a relatively high risk, this may be decreased by increasing the fluid cushion, and decreasing suction pressure. Immediate recognition and endoscopic management of perforation can be highly successful. C-EMR is our suggested method in approaching nonpedunculated colon polyps, especially flat polyps that are not easily accessible by other endoscopic techniques.

Early Gastric Cancer: Current Advances of Endoscopic Diagnosis and Treatment

Endoscopy is a major method for early gastric cancer screening because of its high detection rate, but its diagnostic accuracy depends heavily on the availability of endoscopic instruments. Many novel endoscopic techniques have been shown to increase the diagnostic yield of early gastric cancer. With the improved detection rate of EGC, the endoscopic treatment has become widespread due to advances in the instruments available and endoscopist's experience. The aim of this review is to summarize frequently-used endoscopic diagnosis and treatment in early gastric cancer (EGC).

Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett's neoplasia

BACKGROUND

Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett's neoplasia. Adequate staging is important to assure a good oncological outcome.

OBJECTIVE

The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett's oesophagus (BE) and the cardia.

METHODS

Between November 2005-May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen.

RESULTS

The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%).

CONCLUSION

The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett's dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barrett's dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.

Solutions for submucosal injection in endoscopic resection: a systematic review and meta-analysis

BACKGROUND AND AIMS

Submucosal injection is standard practice in endoscopic mucosal resection of gastrointestinal lesions. Several solutions are used. Our aim was to systematically review their efficacy and safety.

PATIENTS AND METHODS

We performed a systematic review and meta-analysis using a random effects model of randomized controlled trials (RCTs) from MEDLINE. Studies in animal models were qualitatively assessed for efficacy and safety.

RESULTS

In total, 54 studies were qualitatively assessed. Eleven RCTs were analyzed, two of which were on endoscopic submucosal dissection (ESD). The quantitative synthesis included nine RCTs on endoscopic mucosal resection (EMR), comprising 792 subjects and 793 lesions. Mean lesion size was 20.9 mm (range 8.5 - 46 mm). A total of 209 lesions were randomized to sodium hyaluronate (SH) vs normal saline (NS), 72 to 50 % dextrose (D50) vs NS, 82 to D50 vs SH, 43 to succinylated gelatin, 25 to hydroxyethyl starch and 36 to fibrinogen. In total, 385 were randomized to NS as controls. NS and SH are the best studied solutions and seem to be equally effective in achieving complete resection (OR 1.09; 95 %CI 0.82, 1.45). No solution was proven to be superior in complete resection rate, post-polypectomy bleeding or coagulation syndrome/perforation incidence. Many solutions have been tested in animal studies and most seem more effective for mucosal elevation than NS.

CONCLUSIONS

There are several solutions in clinical use and many more under research, but most are poorly studied. SH seems to be clinically equivalent to NS. There are no significant differences in post-polypectomy complications. Larger RCTs are needed to determine any small differences that may exist between solutions.

Endoscopic Submucosal Dissection for Early Gastric Cancer: Getting It Right!

Endoscopic resection is a widely accepted less-invasive treatment technique for local resection of early gastric cancer (EGC) lesions with a negligible risk of lymph node metastasis. Remarkable progress has been made during the last decade in this field, both in terms of expansion of the indications (to larger lesions and to lesions with ulceration) and in terms of technical improvements from endoscopic mucosal resection (EMR) to endoscopic submucosal dissection (ESD). Previously, larger lesions and lesions with ulceration were resected surgically because of the difficulty in effectively using EMR in this context. ESD however allows a high rate of en bloc resections, regardless of tumor location, tumor size, or the presence of ulceration. Nonetheless, ESD also has drawbacks: the procedure time is increased, ESD is more technically challenging compared to EMR, and, finally, ESD is associated with a slightly higher risk of complications. In order to overcome these limitations and minimize complications, a step-by-step process is important for learning ESD techniques. This chapter addresses the indications, results, some technical tips, and complications of ESD for EGC.

Palliative Endoscopic Therapy of Esophageal Cancer

Background

This is a review of endoscopic therapy in the setting of palliative management of patients suffering from esophageal cancer (EC). Unfortunately, many cases of EC present in a stage of disease in which curative therapy is not possible. The maintenance of quality of life includes the ability to swallow and of oral feeding, pain control, and the prevention of bleeding.

Methods

A review of the current literature was performed.

Results

Many endoscopic methods are available for the management of dysphagia, of which dilation, endoluminal tumor destruction, stenting, and brachytherapy are the most common.

Conclusion

Surgical palliation should be avoided as much as possible since the alternatives show at least the same efficacy and have fewer complications.

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.

Improved Techniques for Endoscopic Mucosal Resection (EMR) in Colorectal Adenoma

Background

Endoscopic therapy of colorectal adenomas and early cancers is a standard method. Besides oncological criteria, the method is limited by polyp location, size, and texture.

Method

Based on the current literature, technical modifications and developments in endoscopic mucosal resection are described.

Results

Numerous approaches exist to improve the conditions of resection, including optimisation of mucosal elevation and modification of techniques, tools, and devices.

Conclusion

Endoscopic therapy of sessile and flat colorectal polyps remains a challenge. Some of the presented modifications can help to address this challenge.

The short-term and long-term outcomes of the endoscopic resection for the superficial pharyngeal squamous cell carcinoma

BACKGROUND AND STUDY AIMS

Early detection of superficial pharyngeal squamous cell carcinoma (SPSCC) using narrow-band imaging as well as the increasing use of ER for gastrointestinal cancers may increase the number of ER for SPSCC. The aims of this study were to clarify the feasibility of ER for SPSCC and its long-term outcomes.

PATIENTS AND METHODS

In total, 84 patients with 115 lesions were treated by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) between March 2004 and August 2012. We retrospectively assessed the en bloc and R0 resection rates, complications, lymph node metastasis (LNM), local recurrence, metachronous pharyngeal and esophageal SCC, 5-year overall and cause-specific survival rates.

RESULTS

Higher proportions of en bloc and R0 resection were achieved with ESD compared to EMR (en bloc 100 % vs. 60 %, P < 0.001; R0 59 % vs. 26 %, P < 0.005). There were no significant complications in both groups. None of the patients died from primary SPSCC during the median follow-up of 34 months (range, 3 - 115). LNM occurred in three patients and local recurrence was detected in seven patients (8.3 %) with eight lesions. Tumor thickness over 1000 μm (P < 0.005) and positive or inconclusive horizontal margins (P < 0.05) were significant risk factors for LNM and local recurrence, respectively. Twelve patients died because of co-existing clinical conditions. The 5-year overall and cause-specific survival rates were 80.7 % and 100 %, respectively.

CONCLUSIONS

ER for SPSCC is a feasible treatment with promising results. Tumor thickness over 1000 μm is a significant risk factor for LNM and positive or inconclusive horizontal margin is a risk factor for local recurrence.

Efficacy and safety of 1-week Helicobacter pylori eradication therapy and 7-week rebamipide treatment after endoscopic submucosal dissection of early gastric cancer in comparison with 8-week PPI standard treatment: a randomized, controlled, prospective, multicenter study

BACKGROUND

Endoscopic submucosal dissection (ESD) has been developed for early gastric cancer (EGC). Helicobacter pylori eradication therapy has been reported to have a preventive effect against metachronous recurrence of EGC after ESD. However, the efficacy and safety of eradication therapy on ESD-induced ulcer healing are not clear. In a randomized control study, we compared the standard therapy (8-week proton pump inhibitor) and eradication therapy combined with subsequent treatment with 7-week rebamipide for healing ESD-induced ulcers.

METHODS

A multicenter, randomized, open-label study was conducted. In group A, patients received 20 mg of omeprazole for 56 days. In group B, patients received 40 mg of omeprazole, 1,500 mg of amoxicillin, and 800 mg of clarithromycin for 7 days, and then 300 mg of rebamipide for 49 days. The primary end point was to evaluate the scarring ratio.

RESULTS

The scarring rate in group A was significantly higher than that in group B [85.0 % (34/40) vs. 56.8 % (21/37), P = 0.011]. The scarring rate of ulcers with an area ≥565.5 mm(2) in group A was significantly higher than that in group B [78.9 % (15/19) vs. 37.5 % (6/16), P = 0.018]. There was no significant difference between the groups in the scarring rate of smaller ulcers. No serious adverse events were observed in any of the patients in either group.

CONCLUSION

H. pylori eradication therapy and 7-week rebamipide monotherapy were not superior to PPI monotherapy, but this combination therapy for smaller sized ulcers was an optimal therapeutic option for healing. Serious adverse events were not observed in either group.

Clinical outcomes of no residual disease in the specimen after endoscopic resection for gastric neoplasms

BACKGROUND

No residual disease (NRD) can be found in the specimen after endoscopic resection (ER) of biopsy-proven gastric neoplasm. This study aimed to evaluate the endoscopic and pathologic characteristics of patients with NRD and identify the cause and long-term prognosis.

METHODS

Medical records of patients who underwent ER for biopsy-proven gastric neoplasms at a single tertiary hospital between January 2005 and November 2014 were retrospectively reviewed. Patients whose post-ER histology was revealed as NRD were included. Overall incidence, clinicopathologic characteristics, cause, and long-term prognosis were analyzed.

RESULTS

NRD was detected in 143 (3.2%) of 4401 cases of gastric neoplasms treated with ER. Mean endoscopic size of the initial lesion was 8.15 ± 6.64 mm; in 93 cases (65.0%), the lesion was located in the lower third of the stomach. Initial pathologic diagnosis was as follows: adenoma (n = 110), carcinoma (n = 29), and atypical gland (n = 4). The causes of NRD were minute lesions removed by biopsy in 140 patients, pathologic misdiagnoses in two, and localization error in one. Local recurrence was detected in five patients (3.6%) with minute lesions during follow-up and treated with argon plasma coagulation (n = 4) or re-ER (n = 1). Synchronous (n = 5, 3.6%) and metachronous gastric lesions (n = 6, 4.3%) were also detected during follow-up.

CONCLUSIONS

The main cause of NRD was minute lesions which might be completely removed by initial diagnostic biopsy. These cases showed a minimal rate of local recurrence and synchronous or metachronous gastric neoplasms. Careful follow-up is also mandatory for detection of residual disease.

Detection of superficial esophageal squamous cell neoplasia by chromoendoscopy-guided confocal laser endomicroscopy

AIM: To evaluate the diagnostic potential of Lugol’s chromoendoscopy-guided confocal laser endomicroscopy (CLE) in detecting superficial esophageal squamous cell neoplasia (ESCN).

METHODS: Between December 2008 and September 2010, a total of 52 patients were enrolled at the Chinese PLA General Hospital in Beijing, China. First, Lugol’s chromoendoscopy-guided CLE was performed in these patients and the CLE in vivo histological diagnosis was recorded. Then, chromoendoscopy-guided biopsy was performed in the same patients by another endoscopist who was blinded to the CLE findings. Based on the biopsy and CLE diagnosis, en bloc endoscopic resection was performed. The CLE in vivo diagnosis and the histological diagnosis of biopsy of ESCN were compared, using a histological examination of the endoscopic resection specimens as the standard reference.

RESULTS: A total of 152 chromoendoscopy-guided biopsies were obtained from 56 lesions. In the 56 lesions of 52 patients, a total of 679 CLE images were obtained vs 152 corresponding biopsies. The sensitivity, specificity, negative predictive value and positive predictive value of chromoendoscopy-guided CLE compared with biopsy were 95.7% vs 82% (P < 0.05), 90% vs 70% (P < 0.05), 81.8% vs 46.7% (P < 0.05), and 97.8% vs 92.7% (P > 0.05), respectively. There was a significant improvement in sensitivity, specificity, negative predictive value, and accuracy when comparing chromoendoscopy-guided CLE with biopsy.

CONCLUSION: Lugol’s chromoendoscopy-guided CLE is a real-time, non-invasive endoscopic diagnostic technology; the accuracy of the detection of superficial ESCN is equivalent to or may be superior to biopsy histology.

In vitro assessment of the performance of a new multiband mucosectomy device for endoscopic resection of early upper gastrointestinal neoplasia

Background and study aims

Multiband mucosectomy (MBM) is widely used for the endoscopic resection of early neoplasia in the upper gastrointestinal tract. A new MBM-device may have advantages over the current MBM-device with improved visualization, easier passage of accessories, and higher suction power due to different trip wire and cap.

Methods

Rubber bands were released one by one for both MBM-devices while endoscopic images were collected. First, free endoscopic view was assessed by computer-assisted measurements (quantitative) and by ranking the images by a panel of 11 endoscopists (qualitative). Second, using a visual analog scale, three ‘blinded’ endoscopists assessed introduction and advancement of three types of endoscopic devices through the working channel of a diagnostic endoscope with the MBM-devices assembled. Third, suction power was evaluated by a manometer attached to the cap of the assembled MBM-devices in four endoscopes. Negative pressures were measured after 5 and 10 s of suction and repeated five times. The passage and suction experiments were performed with dry trip wires and repeated after soaking with bloody, mucous fluids.

Results

With all bands present, endoscopic views were 90 and 40 % in the new and current MBM-device, respectively. With the release of more bands, differences slowly disappeared. The panel scored a better endoscopic view in the new MBM-device (p = 0.03). Passage of all accessories was considered significantly easier in the new MBM-device. With the associated snare in the working channel, suction power was significantly better with the new MBM-device.

Conclusion

Compared to the currently available MBM-device, the new MBM-device provides improved endoscopic visibility, smoother passage of accessories, and higher suction power.

Diagnostic Accuracy of Mucosal Biopsy versus Endoscopic Mucosal Resection in Barrett's Esophagus and Related Superficial Lesions

Background. Endoscopic surveillance for early detection of dysplastic or neoplastic changes in patients with Barrett's esophagus (BE) depends usually on biopsy. The diagnostic and therapeutic role of endoscopic mucosal resection (EMR) in BE is rapidly growing. Objective. The aim of this study was to check the accuracy of biopsy for precise histopathologic diagnosis of dysplasia and neoplasia, compared to EMR in patients having BE and related superficial esophageal lesions. Methods. A total of 48 patients with previously diagnosed BE (36 men, 12 women, mean age 49.75 ± 13.3 years) underwent routine surveillance endoscopic examination. Biopsies were taken from superficial lesions, if present, and otherwise from BE segments. Then, EMR was performed within three weeks. Results. Biopsy based histopathologic diagnoses were nondysplastic BE (NDBE), 22 cases; low-grade dysplasia (LGD), 14 cases; high-grade dysplasia (HGD), 8 cases; intramucosal carcinoma (IMC), two cases; and invasive adenocarcinoma (IAC), two cases. EMR based diagnosis differed from biopsy based diagnosis (either upgrading or downgrading) in 20 cases (41.67%), (Kappa = 0.43, 95% CI: 0.170–0.69). Conclusions. Biopsy is not a satisfactory method for accurate diagnosis of dysplastic or neoplastic changes in BE patients with or without suspicious superficial lesions. EMR should therefore be the preferred diagnostic method in such patients.

Outcomes of endoscopic resection for high-grade dysplasia and esophageal cancer

BACKGROUND

Endoscopic resection (ER) is an important advance in the management of esophageal tumors. It has been used successfully for superficial esophageal cancer and high-grade dysplasia (HGD) arising out of Barrett epithelium.

METHODS

From a single institution within the Department of Surgery, patients who underwent ER for esophageal tumors between December 2001 and January 2012 were evaluated. Demographic, clinical, and pathologic variables were collected and reviewed.

RESULTS

We identified 81 patients who underwent ER for esophageal lesions. Median patient age was 69 years, and the median follow-up was 3.25 years. In patients with HGD, at the time of last endoscopy, the complete eradication rate of HGD was 84 % and cancer-specific survival was 100 %. During surveillance, one patient developed an invasive carcinoma that required endoscopic therapy. Patients with T1a and negative deep margins on ER had a recurrence-free and cancer-specific survival of 100 %. There were seven patients with T1b and negative margins on ER. Three patients underwent esophagectomy; final pathology revealed no residual malignancy or lymph node metastasis. Two patients had definitive chemoradiation, and two patients were observed. To date, there has been no cancer recurrence. In all patients who underwent ER, there was one episode of bleeding that required endoscopic treatment and admission for observation.

CONCLUSIONS

ER can be performed safely and can adequately stage and often treat patients with HGD and superficial cancers. Patients with HGD and T1a disease with negative margins are cured with ER alone. Observation and surveillance may be an option for select patients with low-risk, early submucosal disease (T1b) and negative margins.

Diagnosis and staging of superficial esophageal precursor based on pre-endoscopic resection system comparable to endoscopic resection

Background

Endoscopic treatments for early esophageal squamous cell carcinoma and the esophageal neoplasm are two types: endoscopic resection (ER) and ablation. Resection enables evaluation of the lesion in the ER specimens, while ablation cannot. We sought to establish a pre-ER evaluated system with a diagnostic and staging accuracy similar to ER for the development of ablation therapy.

Methods

In our study, we collected data pertaining to early esophageal cancer and esophageal neoplasm treated with ER, analyzed the pre- and post-ER data of the lesions and evaluated the diagnostic accuracy of pre-ER system compared with the gold standard.

Results

The diagnostic accuracy rate was 91% based on the pre-ER system compared with the gold standard, and 93% based on the ER diagnosis. The AUC of the pre-ER system was 0.964, while the ER examination was 0.971.

Conclusion

These results suggest that the accuracy of pre-ER system was comparable to ER. The pre-ER system enables prediction of histological diagnosis and stage of the lesions, and the choice of treatment for superficial esophageal neoplasm.

Long-term recurrence of neoplasia and Barrett's epithelium after complete endoscopic resection

BACKGROUND

Current endoscopic therapy for neoplastic Barrett's oesophagus (BO) consists of complete resection/ablation of all Barrett's tissue including neoplastic lesions. Recurrence seems to be frequent after thermal therapy, such as radiofrequency ablation.

OBJECTIVE

To analyse long-term recurrence of neoplasia and BO after successful widespread endoscopic mucosal resection (EMR).

DESIGN

In a retrospective analysis, all patients undergoing widespread EMR of neoplastic BO between 2002 and 2007 at two referral centres were followed for at least 3 years after completion of endotherapy. Recurrence was diagnosed if neoplasia and/or BO were detected following previous successful complete removal, defined as at least two negative endoscopies and biopsies.

RESULTS

Ninety patients undergoing widespread EMR were included (mean age 63 years; 82 male), 58% of whom underwent additional thermal ablation for minor residual disease. Complete eradication of neoplasia and Barrett's tissue was achieved in 90% of patients. On further follow-up (mean 64.8 months), recurrence of neoplastic and non-neoplastic BO was found in 6.2% and 39.5%, respectively. Recurring neoplasia (3 adenocarcinomas, 1 low-grade and 1 high-grade dysplasia) were found after a median of 44 months (range 38-85) and could be retreated endoscopically. In a multivariate analysis, Barrett's length was the only factor significantly associated with recurrence (OR 2.73).

CONCLUSIONS

Even after seemingly complete endoscopic resection, recurrence of BO is frequent and independent of additional thermal therapy. Due to the possibility of neoplasia recurrence even after long disease-free intervals, follow-up should be extended beyond 5 years.

Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors

Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

Endoluminal resection and tissue acquisition

Endoscopic resection as curative treatment is feasible and indicated for gastrointestinal adenomas and early cancer limited to the mucosal layer and submucosal layers, where the risk for nodal and distant metastases is minimal. The initial technique of endoscopic resection, endoscopic mucosal resection, was limited by the inability to have en bloc resections for lesions larger than 2 cm. This meant that proper assessment of resection margins and depths was not possible in these cases, with the risk of incomplete resection and remnant lesions. In the last decade, the technique of endoscopic submucosal dissection was introduced, and this has allowed en bloc resection of superficial cancers of the esophagus, stomach, and colon. Cumulative data have shown high en bloc resection rates and excellent short-term and long-term outcomes when treatment inclusion criteria are adhered to. Endoscopic resection techniques were recently applied in the context of submucosal lesions. In the case of lesions located in the muscularis mucosa and submucosal layers, the gastrointestinal wall is not breached during endoscopic resection. However, in the case of submucosal lesion located in the muscularis propria layer, endoscopic mucosal resection or endoscopic submucosal dissection would result in perforation which may not be easily closed endoscopically. The technique of endoscopic submucosal tunneling was introduced in the context of peroral endoscopic myotomy for the treatment of achalasia. The principle was extended to the resection of tumors arising from the muscularis propria layer, with promising results.

EMR is not inferior to ESD for early Barrett's and EGJ neoplasia: An extensive review on outcome, recurrence and complication rates

Background and study aims In recent years, it has been reported that early Barrett's and esophagogastric junction (EGJ) neoplasia can be effectively and safely treated using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Multiband mucosectomy (MBM) appears to be the safest EMR method. The aim of this systematic review is to assess the safety and efficacy of MBM compared with ESD for the treatment of early neoplasia in Barrett's or at the EGJ. Methods A literature review of studies published up to May 2013 on EMR and ESD for early Barrett's esophagus (BE) neoplasia and adenocarcinoma at the EGJ was performed through MEDLINE, EMBASE and the Cochrane Library. Results on outcome parameters such as number of curative resections, complications and procedure times are compared and reported. Results A total of 16 studies met the inclusion criteria for analysis in this study. There were no significant differences in recurrence rates when comparing EMR (10/380, 2.6 %) to ESD (1/333, 0.7 %) (OR 8.55; 95 %CI, 0.91 - 80.0, P = 0.06). All recurrences after EMR were treated with additional endoscopic resection. The risks of delayed bleeding, perforation and stricture rates in both groups were similar. The procedure was considerably less time-consuming in the EMR group (mean time 36.7 min, 95 %CI, 34.5 - 38.9) than in the ESD group (mean time 83.3 min, 95 %CI, 57.4 - 109.2). Conclusions The MBM technique for EMR is as effective as ESD when comparing outcomes related to recurrence and complication rates for the treatment of early Barrett's or EGJ neoplasia. The MBM technique is considerably less time-consuming.

Endoscopic treatment for early gastric cancer

Gastric cancer remains one of the most common causes of cancer death. However the proportion of early gastric cancer (EGC) at diagnosis is increasing. Endoscopic treatment for EGC is actively performed worldwide in cases meeting specific criteria. Endoscopic mucosal resection can treat EGC with comparable results to surgery for selected cases. Endoscopic submucosal dissection (ESD) increases the en bloc and complete resection rates and reduces the local recurrence rate. ESD has been performed with expanded indication and is expected to be more widely used in the treatment of EGC through the technological advances in the near future. This review will describe the techniques, indications and outcomes of endoscopic treatment for EGC.

Use of prototype two-channel endoscope with elevator enables larger lift-and-snare endoscopic mucosal resection in a porcine model

Background: Flat and depressed lesions are becoming increasingly recognized in the esophagus, stomach, and colon. Various techniques have been described for endoscopic mucosal resection (EMR) of these lesions.

Aims: To evaluate the efficacy of lift-grasp-cut EMR using a prototype dual-channel forward-viewing endoscope with an instrument elevator in one accessory channel (dual-channel elevator scope) as compared to standard dual-channel endoscopes.

Methods: EMR was performed using a lift-grasp-cut technique on normal flat rectosigmoid or gastric mucosa in live porcine models after submucosal injection of 4 mL of saline using a dual-channel elevator scope or a standard dual-channel endoscope. With the dual-channel elevator scope, the elevator was used to attain further lifting of the mucosa. The primary endpoint was size of the EMR specimen and the secondary endpoint was number of complications.

Results: Twelve experiments were performed (six gastric and six colonic). Mean specimen diameter was 2.27 cm with the dual-channel elevator scope and 1.34 cm with the dual-channel endoscope (P = 0.018). Two colonic perforations occurred with the dual-channel endoscope, vs no complications with the dual-channel elevator scope.

Conclusions: The increased lift of the mucosal epithelium, through use of the dual-channel elevator scope, allows for larger EMR when using a lift-grasp-cut technique. Noting the thin nature of the porcine colonic wall, use of the elevator may also make this technique safer.

Submucosal tunneling techniques: current perspectives

Advances in endoscopic submucosal dissection include a submucosal tunneling technique, involving the introduction of tunnels into the submucosa. These tunnels permit safer offset entry into the peritoneal cavity for natural orifice transluminal endoscopic surgery. Technical advantages include the visual identification of the layers of the gut, blood vessels, and subepithelial tumors. The creation of a mucosal flap that minimizes air and fluid leakage into the extraluminal cavity can enhance the safety and efficacy of surgery. This submucosal tunneling technique was adapted for esophageal myotomy, culminating in its application to patients with achalasia. This method, known as per oral endoscopic myotomy, has opened up the new discipline of submucosal endoscopic surgery. Other clinical applications of the submucosal tunneling technique include its use in the removal of gastrointestinal subepithelial tumors and endomicroscopy for the diagnosis of functional and motility disorders. This review suggests that the submucosal tunneling technique, involving a mucosal safety flap, can have potential values for future endoscopic developments.

Submucosal endoscopy: from ESD to POEM and beyond

Peroral endoscopic myotomy (POEM) is an evolving minimally invasive endoscopic surgical procedure, with no skin incision, intended for long-term recovery from symptoms of esophageal achalasia. POEM was developed based on both the already established surgical principles of esophageal myotomy and the advanced techniques of endoscopic submucosal dissection. This article relates how POEM was developed, and its use in practice is reported and discussed. As an extension of the POEM technique, submucosal endoscopic tumor resection is introduced.

Esophageal ESD: technique and prevention of complications

The advantage of endoscopic submucosal dissection (ESD) is the ability to achieve high R0 resection, providing low local recurrence rate. Esophageal ESD is technically more difficult than gastric ESD due to the narrower space of the esophagus for endoscopic maneuvers. Also, the risk of perforation is higher because of the thin muscle layer of the esophageal wall. Blind dissection should be avoided to prevent perforation. A clip with line method is useful to keep a good endoscopic view with countertraction. Only an operator who has adequate skill should perform esophageal ESD.

Suitability of sentinel node mapping as an index of metastasis in early gastric cancer following endoscopic resection

BACKGROUND

When pathological diagnosis following endoscopic resection (ER) for early gastric cancer (EGC) suggests probable lymph node metastasis, additional surgery with lymphadenectomy should be performed. The sentinel node (SN) concept has yet to be applied to tumors following ER. The aim of this study was to evaluate the feasibility of SN navigation surgery for such tumors.

METHODS

Forty patients diagnosed with EGC lesions <4 cm in diameter underwent gastrectomy with SN mapping following ER. A technetium-99 m tin colloid solution and a dye were injected into the submucosal layer around the post-ER scar in all four abdominal quadrants. We then compared the SN distribution and metastases among the patients who underwent ER and controls (n = 192).

RESULTS

SNs were identifiable in all patients, and the mean number of SNs per case was 4.9. The location of the SN basin was similar in the patients who underwent ER and the controls. One patient (3 %) whose primary tumor had invaded the submucosal layer had a metastatic SN. The median time from ER to surgery was 73 days. No postoperative recurrence was observed in any patient over a median follow-up of 1,023 days.

CONCLUSIONS

Our findings suggest that the SN basin is not greatly affected by ER. The SN concept could be suitable for tumors following ER, but conventional gastrectomy with lymphadenectomy involving the SN basin should be used at present.

Comparison of the long-term outcomes of endoscopic resection for superficial squamous cell carcinoma and adenocarcinoma of the esophagus in Japan

OBJECTIVES

Few studies have simultaneously evaluated the long-term outcomes of endoscopic resection (ER) for squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus in Japan. The objective of this study was to evaluate the long-term outcomes of ER for superficial esophageal cancer in consecutive patients.

METHODS

This was a retrospective study from a single institution. From April 2001 to June 2012, 204 patients with SCC and 26 patients with AC were included from a total of 355 consecutive patients who were treated by esophageal ER at the Tohoku University Hospital. Patients with submucosal invasion deeper than 200 μm and lymphovascular involvement were excluded. The intervention followed was endoscopic therapy.

RESULTS

Overall survival, disease-free survival, and recurrence rates were evaluated as long-term outcomes. In the SCC group, during the median observation time of 36.5 months (range, 6-120 months), 22 (10.8%) patients experienced metachronous recurrence, 4 (2.0%) patients experienced local recurrence, and 27 (13.2%) patients died from causes unrelated to SCC. In the AC group, during the median observation time of 45.5 months (range, 6-131 months), one patient (3.8%) experienced metachronous recurrence and two (7.7%) died from causes unrelated to AC. The cumulative 5-year overall survival rates were not significantly different between SCC (75.9%) and AC (88.9%) (P=0.120). The cumulative 5-year disease-free survival rates of SCC (57.1%) were significantly lower than those of AC (85.2%; P=0.017). The cumulative 5-year recurrence rates of SCC (32.0%) were significantly higher than those of AC (4.2%; P=0.023).

CONCLUSIONS

The rate of recurrence after ER was higher in patients with SCC than that in patients with AC. These findings suggest that, by detecting AC of the esophagus earlier, a satisfactory prognosis without recurrence can be expected after ER in Japan, and more rigorous endoscopic follow-up is necessary after ER in patients with SCC than in those with AC.

One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia

BACKGROUND AND OBJECTIVE

Focal endoscopic mucosal resection (EMR) of visible intraepithelial lesions arising within Barrett's esophagus (BE) may miss synchronous lesions that are not endoscopically apparent. Stepwise radical endoscopic resection would obviate this concern by removing all BE; however, it requires repeated endoscopy which may increase the risk of complications, particularly for patients with circumferential BE. The aim of the study was to evaluate the safety and efficacy of one-step complete circumferential resection of BE by cap-assisted EMR (EMR-C) among patients with circumferential BE and high-grade dysplasia or intramucosal carcinoma.

PATIENTS AND METHODS

Between January 2003 and March 2010, 47 patients with circumferential BE and biopsy-proven high-grade dysplasia or intramucosal cancer underwent EMR-C. We evaluated: (1) complete eradication of neoplasia, (2) complete eradication of metaplasia, and (3) complications including bleeding and esophageal stricture.

RESULTS

Complete eradication of neoplasia and complete eradication of metaplasia were achieved after a median follow-up of 18.4 months in 91% (43/47) of patients. After EMR-C, two patients (one IMC, one invasive cancer) underwent esophagectomy. Histology of the resected specimens showed no residual disease and a T1bN0 lesion, respectively. Two patients had progression of neoplasia. A stenosis occurred in 18 out of 45 patients (40%). All stenoses were treated with dilations and two required temporary placement of a covered stent.

CONCLUSION

One-step complete EMR-C is a safe and effective technique which can be considered in patients with early neoplastic lesions. Although 40% of patients developed dysphagia, this could well be managed endoscopically.

Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a retrospective comparison with conventional endoscopic resection in a single center

BACKGROUND

Few studies have compared the outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in patients with early gastric cancer.

METHODS

We studied 780 lesions for which endoscopic treatment was indicated according to the Japanese Gastric Cancer Association (JGCA) criteria or the extended National Cancer Center (NCC) criteria from April 1995 to December 2007. A total of 359 lesions were treated by endoscopic aspiration mucosectomy (EAM) between April 1995 and March 2003 (EAM group), and 421 lesions were treated by ESD between April 2003 and December 2007 (ESD group). Long-term outcomes (local recurrence rate, overall survival) were compared between the groups.

RESULTS

The median follow-up was 73 months in the EAM group and 65 months in the ESD group. Overall, the local recurrence rate was significantly lower in the ESD group (0.2 %, 1/421) than in the EAM group (4.2 %, 15/359) (p < 0.05). For lesions meeting the JGCA criteria, the local recurrence rate was 2.9 % in the EAM group and 0 % in the ESD group (p < 0.05). For lesions meeting the NCC criteria, the local recurrence rate was 12.5 % in the EAM group and 0.6 % in the ESD group (p < 0.05). There was no significant difference between the groups in overall survival.

CONCLUSIONS

On long-term follow-up, ESD was associated with a lower rate of local recurrence than EAM for lesions that met the JGCA or the NCC criteria. From the point of view of radical curability, ESD can be recommended for the management of lesions that meet either set of criteria.