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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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Kichler AJ, Diehl DL. Wide-field endoscopic mucosal resection of laterally spreading rectal tumors using a multiband ligation endoscopic mucosal resection technique. VideoGIE 2021; 7:53-57. [PMID: 35146224 PMCID: PMC8819476 DOI: 10.1016/j.vgie.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adam J Kichler
- Department of Gastroenterology, Hepatology, and Nutrition, Geisinger Medical Center, Danville, Pennsylvania
| | - David L Diehl
- Department of Gastroenterology, Hepatology, and Nutrition, Geisinger Medical Center, Danville, Pennsylvania
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3
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Abstract
PURPOSE OF REVIEW To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). RECENT FINDINGS EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.
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Affiliation(s)
- Yahya Ahmed
- Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed Othman
- Baylor St Luke's Medical Center, Houston, TX, USA. .,Division of Gastroenterology, Baylor College of Medicine, 7200 Cambridge St., 8th Floor, Suite 8B, Houston, TX, 77030, USA.
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Efficacy of Endoscopic Mucosal Resection for Management of Small Duodenal Neuroendocrine Tumors. Surg Laparosc Endosc Percutan Tech 2016; 25:e134-9. [PMID: 26271024 DOI: 10.1097/sle.0000000000000192] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) for small (<20 mm) duodenal neuroendocrine tumors (NETs) remains controversial because of their rarity. MATERIALS AND METHODS This is a retrospective cohort study of patients with surgically or endoscopically resected duodenal NETs from 2001 to 2011. The primary outcome is the rate of disease-free status following resection. A secondary outcome is the sensitivity of endoscopic ultrasound (EUS) in determining NET appropriateness for EMR. RESULTS Thirty patients underwent resection of duodenal NETs (EMR 20, surgery 10). Tumor was present at the margins in 40% of EMR-resected NETs and 10% of surgically resected NETs. Five patients who underwent EMR had residual disease treated with repeat EMR (3) and surgery (2). EUS demonstrated 96% sensitivity in determining lesions limited to the submucosa. CONCLUSIONS EMR for small duodenal NETs can be a safe and effective alternative to surgery in carefully selected patients. EUS is a useful adjunct in determining depth of invasion for duodenal NETs.
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Basuroy R, Haji A, Ramage JK, Quaglia A, Srirajaskanthan R. Review article: the investigation and management of rectal neuroendocrine tumours. Aliment Pharmacol Ther 2016; 44:332-45. [PMID: 27302838 DOI: 10.1111/apt.13697] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 03/26/2016] [Accepted: 05/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rectal neuroendocrine tumours (NETs) are increasingly identified at endoscopy possibly as a result of bowel cancer screening programmes. AIM To present a review of the literature to aid clinicians in the diagnosis and management of rectal neuroendocrine tumours. METHODS A literature search was conducted through MEDLINE using search terms: rectal, rectum, carcinoid, NET, therapy, endoscopy, mucosal resection, submucosal dissection. Relevant articles were identified through manual review with reference lists reviewed for additional articles. RESULTS The incidence of rectal neuroendocrine tumours is approximately 1 per 100 000 population per year with the majority (80-90%) being <1 cm and localised to the submucosa. Metastatic disease is infrequent (<20%) with risk factors including size, atypical appearance, grade and depth of invasion. The primary resection modality influences complete resection rates and the need for secondary therapy. A thorough pre-resection diagnostic work up is required for lesions that are at higher risk of invasion and metastasis. Device-assisted endoscopic mucosal resection and endoscopic submucosal dissection are used to resect localised rectal neuroendocrine tumours <2 cm. Transanal surgery is also used to resect localised 1-2 cm rectal neuroendocrine tumours. Oncological surgical resection is used for rectal neuroendocrine tumours that are >2 cm or with invasion and regional disease. The treatment of advanced disease is multimodal. CONCLUSIONS The long-term tumour biology of small rectal neuroendocrine tumours remains unclear. There is uncertain impact from bowel cancer screening programmes on rectal neuroendocrine tumour incidence, morbidity and mortality. Referral to neuroendocrine tumour centres for patients with locally advanced disease or metastatic disease is recommended.
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Affiliation(s)
- R Basuroy
- ENETS Neuroendocrine Centre of Excellence, Institute of Liver studies, Kings College Hospital, London, UK
| | - A Haji
- ENETS Neuroendocrine Centre of Excellence, Institute of Liver studies, Kings College Hospital, London, UK
| | - J K Ramage
- ENETS Neuroendocrine Centre of Excellence, Institute of Liver studies, Kings College Hospital, London, UK.,Gastroenterology Department, Hampshire Hospitals NHS Trust, Hampshire, UK
| | - A Quaglia
- Histopathology Department, ENETS Neuroendocrine Centre of Excellence, Institute of Liver studies, Kings College Hospital, London, UK
| | - R Srirajaskanthan
- ENETS Neuroendocrine Centre of Excellence, Institute of Liver studies, Kings College Hospital, London, UK.,Gastroenterology Department, University Hospital Lewisham, London, UK
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Ellsmere J, Jones D, Pleskow D, Chuttani R. Endoluminal Instrumentation Is Changing Gastrointestinal Surgery. Surg Innov 2016; 13:145-51. [PMID: 17012156 DOI: 10.1177/1553350606291470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- James Ellsmere
- Section of Minimally Invasive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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7
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Hwang JH, Konda V, Abu Dayyeh BK, Chauhan SS, Enestvedt BK, Fujii-Lau LL, Komanduri S, Maple JT, Murad FM, Pannala R, Thosani NC, Banerjee S. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82:215-26. [PMID: 26077453 DOI: 10.1016/j.gie.2015.05.001] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/01/2015] [Indexed: 02/06/2023]
Abstract
EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.
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Ang TL, Seewald S. Endoluminal resection and tissue acquisition. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:140-153. [PMID: 24609890 DOI: 10.1007/s11938-014-0010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Simei, Singapore, 529889,
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9
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Conio M, Fisher DA, Blanchi S, Ruggeri C, Filiberti R, Siersema PD. One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia. Clin Res Hepatol Gastroenterol 2014; 38:81-91. [PMID: 23856637 DOI: 10.1016/j.clinre.2013.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/24/2013] [Accepted: 05/29/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Massimo Conio
- Department of Gastroenterology, General Hospital, Sanremo, Italy.
| | - Deborah A Fisher
- Department of Gastroenterology, Durham Veterans Affairs Medical Center and Duke Medical Center, NC, USA
| | - Sabrina Blanchi
- Department of Gastroenterology, General Hospital, Sanremo, Italy
| | | | - Rosa Filiberti
- Epidemiology, Biostatistics and Clinical Trials, IRCCS, San Martino - IST National Institute for Cancer Research, Genova, Italy
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
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10
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Haidry RJ, Dunn JM, Butt MA, Burnell MG, Gupta A, Green S, Miah H, Smart HL, Bhandari P, Smith LA, Willert R, Fullarton G, Morris J, Di Pietro M, Gordon C, Penman I, Barr H, Patel P, Boger P, Kapoor N, Mahon B, Hoare J, Narayanasamy R, O'Toole D, Cheong E, Direkze NC, Ang Y, Novelli M, Banks MR, Lovat LB. Radiofrequency ablation and endoscopic mucosal resection for dysplastic barrett's esophagus and early esophageal adenocarcinoma: outcomes of the UK National Halo RFA Registry. Gastroenterology 2013; 145:87-95. [PMID: 23542069 DOI: 10.1053/j.gastro.2013.03.045] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 03/13/2013] [Accepted: 03/21/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) or early neoplasia increasingly receive endoscopic mucosal resection and radiofrequency ablation (RFA) therapy. We analyzed data from a UK registry that follows the outcomes of patients with BE who have undergone RFA for neoplasia. METHODS We collected data on 335 patients with BE and neoplasia (72% with HGD, 24% with intramucosal cancer, 4% with low-grade dysplasia [mean age, 69 years; 81% male]), treated at 19 centers in the United Kingdom from July 2008 through August 2012. Mean length of BE segments was 5.8 cm (range, 1-20 cm). Patients' nodules were removed by endoscopic mucosal resection, and the patients then underwent RFA every 3 months until all areas of BE were ablated or cancer developed. Biopsies were collected 12 months after the first RFA; clearance of HGD, dysplasia, and BE were assessed. RESULTS HGD was cleared from 86% of patients, all dysplasia from 81%, and BE from 62% at the 12-month time point, after a mean of 2.5 (range, 2-6) RFA procedures. Complete reversal dysplasia was 15% less likely for every 1-cm increment in BE length (odds ratio = 1.156; SE = 0.048; 95% confidence interval: 1.07-1.26; P < .001). Endoscopic mucosal resection before RFA did not provide any benefit. Invasive cancer developed in 10 patients (3%) by the 12-month time point and disease had progressed in 17 patients (5.1%) after a median follow-up time of 19 months. Symptomatic strictures developed in 9% of patients and were treated by endoscopic dilatation. Nineteen months after therapy began, 94% of patients remained clear of dysplasia. CONCLUSIONS We analyzed data from a large series of patients in the United Kingdom who underwent RFA for BE-related neoplasia and found that by 12 months after treatment, dysplasia was cleared from 81%. Shorter segments of BE respond better to RFA; http://www.controlled-trials.com, number ISRCTN93069556.
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Affiliation(s)
- Rehan J Haidry
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jason M Dunn
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohammed A Butt
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew G Burnell
- Department of Biostatistics, University College London, London, United Kingdom
| | - Abhinav Gupta
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sarah Green
- National Medical Laser Centre, University College London, London, United Kingdom
| | - Haroon Miah
- National Medical Laser Centre, University College London, London, United Kingdom
| | - Howard L Smart
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | | | - Lesley Ann Smith
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Robert Willert
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | | | - John Morris
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | | | | | - Ian Penman
- Royal Infirmary Edinburgh, Edinburgh, United Kingdom
| | - Hugh Barr
- Gloucestershire Hospital NHS Trust, Gloucestershire, United Kingdom
| | - Praful Patel
- Southampton University Hospital, Southampton, United Kingdom
| | - Philip Boger
- Southampton University Hospital, Southampton, United Kingdom
| | - Neel Kapoor
- Aintree University Hospital, Liverpool, United Kingdom
| | - Brinder Mahon
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | | | | - Edward Cheong
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | | | - Yeng Ang
- Centre of Gastrointestinal Sciences, University of Manchester, Salford Royal Foundation NHS Trust, Salford, United Kingdom
| | - Marco Novelli
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew R Banks
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Laurence Bruce Lovat
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom.
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11
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Wani S, Abrams J, Edmundowicz SA, Gaddam S, Hovis CE, Green D, Gupta N, Higbee A, Bansal A, Rastogi A, Early D, Lightdale CJ, Sharma P. Endoscopic mucosal resection results in change of histologic diagnosis in Barrett's esophagus patients with visible and flat neoplasia: a multicenter cohort study. Dig Dis Sci 2013; 58:1703-9. [PMID: 23633158 PMCID: PMC4309270 DOI: 10.1007/s10620-013-2689-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 04/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are limited data on the effect of endoscopic mucosal resection (EMR) on changes of histopathologic diagnosis for Barrett's esophagus (BE) patients undergoing endoscopic eradication therapy (EET); especially those without visible lesions. AIM To compare the frequency of changes of diagnosis by EMR compared with pre-EMR biopsy diagnosis for patients with and without visible lesions. METHODS In this multicenter outcomes project, patients with Barrett's-related neoplasia undergoing EET at three tertiary-care centers were included. Patients undergoing biopsies followed by EMR within six months were included. The main outcome measures were frequency of overall change of histopathologic diagnosis, change based on pre-EMR biopsy diagnosis, and change based on the presence of visible lesions. RESULTS One-hundred and thirty-eight BE patients (low-grade dysplasia (LGD) 15 (10.9 %), high-grade dysplasia (HGD) 87 (63 %), esophageal adenocarcinoma (EAC) 36 (26.1 %)) were included; 114 (82.6 %) patients had visible lesions. EMR resulted in a change of diagnosis for 43 (31.1 %) patients (upgrade 14 (10.1 %); downgrade 29 (21 %)). For HGD patients, EMR downstaged dysplasia grade for 17 (19.5 %) cases and upstaged it to EAC for nine (10.3 %) cases. There was a change of diagnosis for 26 (29.9 %) HGD patients, irrespective of the presence or absence of visible lesions (p = 0.76). For EAC patients, EMR downstaged dysplasia grade in 10 (27.8 %) cases. There was a change of diagnosis for 10 (27.8 %) EAC patients, irrespective of the presence or absence of endoscopically visible lesions (p = 0.48). CONCLUSIONS EMR results in a change of diagnosis for approximately 30 % of BE patients with early neoplasia (with and without visible lesions) referred for EET.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, CO, USA
| | - Julian Abrams
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christine E. Hovis
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Green
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gupta
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - April Higbee
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Ajay Bansal
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Dayna Early
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles J. Lightdale
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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12
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Abstract
Barrett's esophagus (BE) is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium. Endoscopy with systemic biopsy protocols plays a vital role in diagnosis. Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia. These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy. A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa, followed by long-term surveillance improves the outcomes of BE. Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy, radiofrequency ablation and cryotherapy. Debatable issues such as durability of response, recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further. Development of safer wide field resection techniques, which would effectively remove all BE and obviate the need for long-term surveillance, is another research goal. Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.
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13
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Zuercher BF, George M, Escher A, Piotet E, Ikonomidis C, Andrejevic SB, Monnier P. Stricture prevention after extended circumferential endoscopic mucosal resection by injecting autologous keratinocytes in the sheep esophagus. Surg Endosc 2012; 27:1022-8. [PMID: 22955900 DOI: 10.1007/s00464-012-2509-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 07/03/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND During the past decades, endoscopic mucosal resection (EMR) has been developed to treat early intramucosal esophageal cancers and dysplastic Barrett's esophagus. The primary drawback of this method is severe postsurgical esophageal stricture formation. The purpose of this preclinical study was to assess strategies for prevention of this major complication by injecting autologous keratinocytes in the EMR mucosal defect in the sheep model. METHODS Circumferential, 6-cm-long EMRs were performed in the esophagus of nine sheep. Autologous keratinocytes were harvested 2 weeks before EMR and cultured. Circumferential resection consisted of two opposite hemicircumferential mucosectomies allowing a widespread resection of 24 cm(2). Immediately after EMR, autologous keratinocytes were endoscopically injected in the mucosal defect. Animals were sacrificed after 6 months. RESULTS Circumferential EMRs were successfully performed in all animals. There were no intra- or postoperative complications. None of the animals developed strictures. All animals were sacrificed at 6 months as planned. Histological examinations showed fibrotic changes in 10 % (range 0-25 %) of the circumferential muscularis propria interna layer and 7.2 % (range 0-25 %) in the muscularis propria externa layer at the midportion of the EMR. No circumferential transmural fibrosis was identified. CONCLUSIONS Prevention of stricture formation after extensive (6-cm long) circumferential EMR of the sheep esophagus can be achieved by injecting autologous keratinocytes into the wound of the resected mucosal segment.
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Affiliation(s)
- Barbara F Zuercher
- Head and Neck Surgery, Department of Oto-Rhino-Laryngology, University Hospital (CHUV), Lausanne, Switzerland.
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14
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Abstract
Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.
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Affiliation(s)
- Aparna Repaka
- Division of Gastroenterology, University Hospitals Case Medical Center, Case Western Reserve University, Wearn 247, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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15
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Bhat YM, Furth EE, Brensinger CM, Ginsberg GG. Endoscopic Resection with Ligation Using a Multi-Band Mucosectomy System in Barrett's Esophagus with High-Grade Dysplasia and Intramucosal Carcinoma. Therap Adv Gastroenterol 2011; 2:323-30. [PMID: 21180580 DOI: 10.1177/1756283x09346794] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Endoscopic therapy for early neoplasia in Barrett's esophagus (BE) is evolving. Endoscopic resection has an increasing role. We wanted to evaluate the safety and efficacy of multi-band ligation/resection [ER-L] without pre-injection in BE with high-grade dysplasia [HGD] and intramucosal carcinoma [IMCA]. METHODS A cohort of 65 consecutive patients from a single academic medical center, who underwent ER-L as part of endoscopic eradication therapy for BE with HGD/IMCA were studied. ER-L was performed afterendoscopic mapping and endoscopic ultrasound (EUS). Subsequently, adjunctive ablative therapies including photodynamic therapy, argon plasma coagulation and radiofrequency ablation were applied to achieve complete eradication of all BE. Thereafter biopsy surveillance was performed per protocol. All patients were prescribed a proton-pump inhibitor. MAIN OUTCOME MEASUREMENTS Change in histopathological stage; eradication of BE and HGD/IMCA; adverse events. RESULTS The median number of ER-L applications in each session was 4 (range 1-6) and the mean total number of ER-L sessions was 1.5. Compared with prior forceps biopsy, histopathology from the ER-L specimen changed in 24 (37.5%, p = <0.0001). With median follow-up of 15 months (range 8-42), complete and durable BE eradication was achieved with ER-L alone in 36 (60%) and the remainder with adjunctive ablation therapies. There were nine complications (four (6%) acute bleeding, five (7.5%) strictures, zero perforations). CONCLUSIONS ER-L without submucosal (SM) pre-injection is safe and effective when applied selectively for eradication of BE with HGD/IMCA. There is significant change in pathological stage after ER-L conferring a diagnostic and staging advantage. ER-L may be used adjunctively with ablation therapies.
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Affiliation(s)
- Yasser M Bhat
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Seewald S, Ang TL, Soehendra N. Endoscopic mucosal resection—multiband ligation. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Crumley ABC, Going JJ, McEwan K, McKernan M, Abela JE, Shearer CJ, Stanley AJ, Stuart RC. Endoscopic mucosal resection for gastroesophageal cancer in a U.K. population. Long-term follow-up of a consecutive series. Surg Endosc 2010. [PMID: 20623237 DOI: 10.1007/s00464-010-1213-1219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) of early gastric and esophageal tumors is effective and avoids the morbidity and mortality of surgery. We report the long-term results of a consecutive series of 93 endoscopic resections, during a 7-year period, in a U.K. population. METHODS Eighty-eight patients with 93 lesions were included. EMR was performed for 64 and 29 malignant and benign lesions, respectively. Patients with malignant disease were subgrouped into "high risk" or "low risk" for recurrence. RESULTS Of the 35 lesions in the low-risk group, local control was achieved in 31; 29 after 1 EMR session. Two had residual invasive carcinoma, one had treatment ceased due to pancreatic cancer, and one patient did not attend follow-up. Of the 29 lesions in the high-risk group, local control was achieved in 15; 13 after 1 EMR session. Median follow-up was 53 months. Cancer specific survival for the 45 invasive cancers (T1m and T1sm) was 93%; three patients died from their disease. CONCLUSIONS This study has shown for the first time in a U.K. population that EMR is effective in controlling disease in patients with local high grade dysplasia (HGD) and early invasive carcinoma, with no mortality and low morbidity.
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Affiliation(s)
- Andrew B C Crumley
- University Department of Surgery, Royal Infirmary, Glasgow, G31 2ER, UK.
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Endoscopic mucosal resection for gastroesophageal cancer in a U.K. population. Long-term follow-up of a consecutive series. Surg Endosc 2010; 25:543-8. [DOI: 10.1007/s00464-010-1213-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 06/11/2010] [Indexed: 12/29/2022]
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Garud SS, Keilin S, Qiang Cai, Willingham FF. Diagnosis and management of Barrett's esophagus for the endoscopist. Therap Adv Gastroenterol 2010; 3:227-38. [PMID: 21180605 PMCID: PMC3002583 DOI: 10.1177/1756283x10365439] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
In Barrett's esophagus, the stratified squamous epithelium lining the esophagus is replaced by specialized intestinal-type columnar epithelium. The prevalence of Barrett's esophagus has ranged from 0.9% to 4.5%. The rate of progression from Barrett's esophagus to esophageal adenocarcinoma is 0.5% per patient-year. Proton-pump inhibitors are the mainstay of symptom control in Barrett's patients. Nondysplastic Barrett's and Barrett's with low-grade dysplasia (LGD) are typically managed by periodic surveillance. Radiofrequency ablation is being evaluated as a modality for managing nondysplastic Barrett's and Barrett's with LGD. The options for the management of Barrett's patients with high-grade dysplasia (HGD) include endoscopic therapy, surgery, and intensive surveillance until biopsy reveals adenocarcinoma. Endoscopic therapy involves endoscopic mucosal resection (EMR) and ablation. More aggressive techniques such as endoscopic submucosal dissection and larger segment endoscopic mucosal resection are under study. In this review, we discuss the diagnosis and management of Barrett's esophagus. The recommendations from the major gastroenterologic societies and the current and investigational endoscopic modalities for the management of Barrett's esophagus with and without dysplasia are reviewed.
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Affiliation(s)
- Sagar S. Garud
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Field F. Willingham
- Division of Digestive Diseases, Emory University School of Medicine, 1365 Clifton Road, NE, Atlanta, GA 30322, USA,
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Chennat J, Konda VJA, Ross AS, de Tejada AH, Noffsinger A, Hart J, Lin S, Ferguson MK, Posner MC, Waxman I. Complete Barrett's eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma--an American single-center experience. Am J Gastroenterol 2009; 104:2684-92. [PMID: 19690526 DOI: 10.1038/ajg.2009.465] [Citation(s) in RCA: 175] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) is the endoscopic removal of all Barrett's epithelium with the curative intent of eliminating high-grade dysplasia (HGD)/intramucosal carcinoma (IMC) and reducing the risk of metachronous lesion development. We report our single tertiary referral center's long-term clinical experience using this modality in HGD/IMC management. METHODS In this study, we retrospectively reviewed all patients who had CBE-EMR for Barrett's esophagus (BE) with HGD/IMC who had been entered into our center's prospectively collected database. High-definition white-light and narrow-band imaging examinations were used according to the protocol. Staging endoscopic ultrasound was done before CBE-EMR to exclude invasive disease or suspicious lymphadenopathy. High-dose proton pump inhibition was instituted after initial treatment, and Seattle-type surveillance biopsies were performed on follow-up every 6 months once the CBE-EMR procedure was completed. RESULTS A total of 49 patients (mean age 67 years, median 65, s.d. 11; 75% men) with histologically confirmed BE and HGD (33), IMC (16), underwent CBE-EMR from August 2003 to August 2008. The mean BE segment length was 3.2 cm (median 2, s.d. 2.2); 26 patients had short-segment BE, and 30 had visible lesions. A total of 106 EMR procedures were performed. On initial EMR, two patients had superficial submucosal carcinoma invasion (sm1) and two had IMC with lymphatic channel invasion. All four patients were referred for esophagectomy, but one opted for continued endoscopic management, without evidence of residual or recurrent carcinoma. A total of 14 patients await completion of EMR (9) or first follow-up endoscopy (5). CBE-EMR therapy was completed in 32 patients by an average of 2.1 sessions (median 2, s.d. 0.9). Surveillance biopsies showed normal squamous epithelium in 31 of 32 (96.9%) patients (mean remission time 22.9 months, median 17, s.d. 16.7, interquartile range 11-38). In all, 10 of 46 patients who continued in the endoscopic protocol had subsquamous Barrett's epithelium on EMR specimens and/or treatment endoscopy biopsies. Overall, 1 of these 10 patients had Barrett's underneath squamous mucosa on most recent surveillance biopsies. CBE-EMR upstaged pre-EMR pathology results in 7 of 49 (14%) of patients and downstaged pathology in 15 of 49 (31%) patients. In all, 18 of 49 (37%) patients developed symptomatic esophageal stenosis after a mean of 24.4 days (median 13.5, s.d. 27.8); all were successfully managed by endoscopic treatment. No perforations or uncontrollable bleeding occurred. CONCLUSIONS To our knowledge, this is the largest American single-center experience demonstrating that CBE-EMR with close endoscopic surveillance is an effective treatment modality for BE with HGD/IMC. Although the rate of stenosis development is significant, it is easily treated by endoscopic dilation. Patients considering endoscopic ablation should be counseled appropriately. The role of CBE-EMR in patients with lymphatic invasion or superficial submucosal invasion remains to be defined.
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Affiliation(s)
- Jennifer Chennat
- Department of Medicine, Section of Gastroenterology, CERT (Center for Endoscopic Research and Therapeutics), University of Chicago Medical Center, Chicago, Illinois 60637-1463, USA
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Arezzo A, Pagano N, Romeo F, Delconte G, Hervoso C, Morino M, Repici A. Hydroxy-propyl-methyl-cellulose is a safe and effective lifting agent for endoscopic mucosal resection of large colorectal polyps. Surg Endosc 2008; 23:1065-9. [DOI: 10.1007/s00464-008-0133-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 07/11/2008] [Accepted: 07/31/2008] [Indexed: 01/15/2023]
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22
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Liu J, Petersen BT, Tierney WM, Chuttani R, Disario JA, Coffie JMB, Mishkin DS, Shah RJ, Somogyi L, Song LMWK. Endoscopic banding devices. Gastrointest Endosc 2008; 68:217-21. [PMID: 18656592 DOI: 10.1016/j.gie.2008.03.1121] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 03/31/2008] [Indexed: 01/27/2023]
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Wells CD, Harrison ME, Gurudu SR, Crowell MD, Byrne TJ, Depetris G, Sharma VK. Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation. Gastrointest Endosc 2008; 68:231-6. [PMID: 18533150 DOI: 10.1016/j.gie.2008.02.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 02/04/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage. Treatment of GAVE with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Endoscopic band ligation (EBL) has become the standard treatment of varices because it effectively obliterates the submucosal plexus of esophageal varices with an acceptably low rate of complications. Additionally, EBL has been used for control of bleeding from other GI vascular lesions. In patients with GAVE and recurrent GI hemorrhage, EBL may offer an alternative to ETT for treatment of large areas of diseased mucosa and submucosa. OBJECTIVE Our purpose was to compare EBL (n = 9) with ETT (n = 13) for the treatment of bleeding from GAVE. DESIGN Observational comparative study. PATIENTS Patients with gastric antral vascular ectasia with occult or overt bleeding. SETTING Mayo Clinic Arizona, a multispecialty academic medical center. INTERVENTION EBL or ETT with argon plasma coagulation or electrocautery. MAIN OUTCOME AND MEASUREMENTS Number of treatments to cessation of bleeding and posttreatment hemoglobin, hospitalization, and transfusion requirement. RESULTS There were no significant differences in the demographics, clinical presentation, associated portal hypertension, or mean hemoglobin values or the mean number of transfusions or hospitalizations between the 2 groups before treatment. Four patients in the EBL group had failed prior ETT. Compared with ETT, in exploratory statistical testing EBL had a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period. Analysis of covariance showed significantly superior efficacy of EBL for cessation of bleeding, postprocedure transfusion, and hospitalization. One patient in the EBL group had postprocedure emesis and 1 in the ETT group had immediate post procedure bleeding. All patients in the EBL group had complete mucosal healing with minimal residual GAVE at follow-up endoscopy failed post-EBL. CONCLUSIONS Our initial experience suggests that EBL is superior to ETT for the management of GAVE. EBL required fewer treatment sessions for control of bleeding, had higher rates for cessation of bleeding, had a reduction in hospitalizations and transfusion requirements, and allowed for a significant increase in hemoglobin values.
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Affiliation(s)
- Christopher D Wells
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Ginsberg GG. Endoscopic approaches to Barrett's oesophagus with high-grade dysplasia/early mucosal cancer. Best Pract Res Clin Gastroenterol 2008; 22:751-72. [PMID: 18656828 DOI: 10.1016/j.bpg.2008.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This chapter will review the endoscopic approaches to the management of Barrett's oesophagus with high-grade dysplasia/early mucosal cancer. Factors to consider when evaluating patients for endoscopic management are detailed. Ablation and resection methods for eradication of Barrett's oesophagus with high-grade dysplasia/early mucosal cancer are reviewed. Strategies for combining therapies to achieve safe and effective eradication are discussed. Recommendations for complete eradication of all Barrett's mucosa and follow-up considerations are put forward.
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Affiliation(s)
- Gregory G Ginsberg
- Hospital of the University of Pennsylvania, School of Medicine, Gastroenterology Division, 3rd floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Kantsevoy SV, Adler DG, Conway JD, Diehl DL, Farraye FA, Kwon R, Mamula P, Rodriguez S, Shah RJ, Wong Kee Song LM, Tierney WM. Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 2008; 68:11-8. [PMID: 18577472 DOI: 10.1016/j.gie.2008.01.037] [Citation(s) in RCA: 258] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 01/31/2008] [Indexed: 02/08/2023]
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Seewald S, Ang TL, Soehendra N. Endoscopic mucosal resection of Barrett's oesophagus containing dysplasia or intramucosal cancer. Postgrad Med J 2007; 83:367-72. [PMID: 17551066 PMCID: PMC2600047 DOI: 10.1136/pgmj.2006.054841] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Barrett's oesophagus is premalignant. Oesophagectomy is traditionally regarded as the standard treatment option in the presence of high grade intraepithelial neoplasia or intramucosal cancer. However, oesophagectomy is associated with high rates of mortality and morbidity. Endoscopic ablative therapies are limited by the lack of tissue for histological assessment, and the ablation may be incomplete. Endoscopic mucosal resection is an alternative to surgery in the management of high grade intraepithelial neoplasia and intramucosal cancer. It is less invasive than surgery and, unlike ablative treatments, provides tissue for histological assessment. This review will cover the indications, techniques and results of endoscopic mucosal resection.
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Affiliation(s)
- S Seewald
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Katsinelos P, Kountouras J, Paroutoglou G, Zavos C, Rizos C, Beltsis A. Endoscopic mucosal resection of large sessile colorectal polyps with submucosal injection of hypertonic 50 percent dextrose-epinephrine solution. Dis Colon Rectum 2006; 49:1384-92. [PMID: 16897333 DOI: 10.1007/s10350-006-0611-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Before endoscopic mucosal resection of large sessile colorectal polyps, injection of solution into submucosa cushions and isolates the tumor, although there is little information as to which solution with optimal effect should be used. This study investigated the effectiveness of endoscopic mucosal resection by use of a hypertonic dextrose plus epinephrine solution for large sessile colorectal polyps. METHODS We removed 59 large sessile colorectal polyps in 59 patients by introducing an endoscopic submucosal hypertonic dextrose plus epinephrine injection technique. Endoscopic evaluations were repeated at 3, 6, and 12 months or longer. If no residual tumor was observed endoscopically and histologically at one year or more, the patient was considered to be "cured." The main outcome measurements were the mean amount of solution injected, mean disappearance time of solution, safety, complications, and recurrence at follow-up. RESULTS Of the 59 large sessile colorectal polyps, 23 (39 percent) were resected en bloc and 36 (61 percent) piecemeal. The mean amount of hypertonic dextrose plus epinephrine solution injected was 24.42 +/- 17.52 ml, and its mean disappearance time was 13.61 +/- 5.21 (range, 7-21) minutes. Of the 36 patients treated with piecemeal resection, 18 (50 percent) required additional endoscopic interventions. In patients who entered the follow-up surveillance protocol for one year or longer, the cure rate by en bloc resection was 100 percent (23/23) and that by piecemeal intervention was 96.78 percent (30/31). Four patients (6.8 percent) had local bleeding after endoscopic mucosal resection that was mainly controlled endoscopically. CONCLUSIONS Endoscopic mucosal resection after submucosal hypertonic dextrose plus epinephrine solution injection, with an intensive follow-up program, seems to be a safe and effective treatment for large sessile colorectal polyps.
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Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, Central Hospital, Thessaloniki, Macedonia 551 33, Greece
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Soehendra N, Seewald S, Groth S, Omar S, Seitz U, Zhong Y, de Weerth A, Thonke F, Schroeder S. Use of modified multiband ligator facilitates circumferential EMR in Barrett's esophagus (with video). Gastrointest Endosc 2006; 63:847-52. [PMID: 16650552 DOI: 10.1016/j.gie.2005.06.052] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Accepted: 06/29/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Various techniques are available for EMR in the upper- and lower-GI tract. For early cancers of the esophagus, the "suck and cut" technique, which uses a transparent cap or variceal band ligator, is the most commonly practiced method. To facilitate multiple or circumferential EMR, a modified multiband variceal ligator (MBL) is introduced, which allows sequential banding and snare resection without the need to withdraw the endoscope. OBJECTIVE To study the feasibility of modified MBL device in facilitating circumferential EMR of Barrett's esophagus (BE) that contains high-grade intraepithelial neoplasia (HGIN) and/or intramucosal cancer (IMC). DESIGN To enable band delivery with a snare inserted in the therapeutic endoscope, the threading channel of the cranking device is enlarged from 2 to 3.2 mm. The 6-shooter MBL was used. PATIENTS Ten consecutive patients (all men; median age, 62 years; range 43-82 years) with BE were treated. IMC and HGIN were found in 8 and 2 patients, respectively. INTERVENTIONS EMR was performed with pure coagulating current when using a 1.5 x 2.5-cm mini hexagonal polypectomy snare. No submucosal saline solution injection was performed before resection. RESULTS In 5 of 10 patients with circumferential BE of 2 to 9 cm in length (median, 4 cm), complete circumferential EMR was performed in 1 session by using 3 to 18 bands (median, 6). Four patients with 3- to 10-cm (median, 4 cm) long segment BE required 2 to 5 sessions (median, 3) with a total of 5 to 42 bands (median, 12). Another patient with multifocal HGIN and/or IMC in 24 of a total of 49 specimens was finally recommended for surgery because of technical difficulties caused by mural thickening after 4 sessions. No serious procedure-related complications were observed, except for 2 minor bleedings, which were controlled endoscopically. Seven patients developed strictures after circumferential EMR. All patients except 1 were successfully managed by weekly bougienage after a median of 5 sessions (range 3-11). Deep-wall tears developed in 1 patient during the fourth bougienage session, for which limited distal esophageal resection was performed with an uneventful outcome. CONCLUSIONS The novel technique of MBL-EMR described here facilitated and simplified circumferential removal of BE that contained HGIN and/or IMC. However, the method is associated with a very high stricture rate if circumferential EMR is performed in a single session. Complete removal of BE should be achieved by repeated partial EMR. Long-term follow-up is needed to observe for late recurrence and to determine the clinical impact of this method.
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Affiliation(s)
- Nib Soehendra
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Seewald S, Soehendra N. Perforation: part and parcel of endoscopic resection? Gastrointest Endosc 2006; 63:602-5. [PMID: 16564859 DOI: 10.1016/j.gie.2005.08.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2005] [Accepted: 08/27/2005] [Indexed: 02/08/2023]
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Abstract
Techniques of endoscopic mucosal resection (EMR) can dramatically improve the ability to diagnose and treat superficial lesions in the gastrointestinal (GI) tract. Early cancers, submucosal tumors, and sessile polyps can be safely and completely removed in a single procedure, with long-term outcome results comparable to surgery. This is accomplished with a minimum cost, morbidity, and mortality and with little or no impact on the quality of life of patients. This article provides an overview of the techniques, indications, and outcomes of EMR in the management of GI malignancy.
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Affiliation(s)
- Alberto Larghi
- Department of Endoscopy and Therapeutics, Section of Gastroenterology, The University of Chicago, MC 9028, Illinois 60637, USA
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Monkewich GJ, Haber GB. Novel endoscopic therapies for gastrointestinal malignancies: endoscopic mucosal resection and endoscopic ablation. Med Clin North Am 2005; 89:159-86, ix. [PMID: 15527813 DOI: 10.1016/j.mcna.2004.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Gastrointestinal malignancies are often detected at advanced stages when the prognosis is poor. Screening guidelines that vary accord-ing to the regional disease prevalence are needed. High-resolution endoscopy, magnification endoscopy, chromoendoscopy, light autofluorescence endoscopy, and optical coherence tomography are new technologies designed to improve endoscopic detection. Once detected, lesions must be accurately staged, including depth of mucosal penetration and lymph node involvement, to determine endoscopic resectability. Widely applicable, relatively safe, and minimally invasive alternatives to surgery are needed. Endoscopic mucosal resection and endoscopic ablation are potentially curative for malignancies limited to the mucosa, obviating the need for surgery in these patients.
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Affiliation(s)
- Gregory J Monkewich
- Gastroenterology and Therapeutic Endoscopy, 2055 York Avenue, Suite 325, Vancouver, British Columbia V6J 1E5, Canada.
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N/A CT. N/A. Shijie Huaren Xiaohua Zazhi 2003; 11:632-634. [DOI: 10.11569/wcjd.v11.i5.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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Ono A, Fujii T, Saito Y, Matsuda T, Lee DTY, Gotoda T, Saito D. Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device. Gastrointest Endosc 2003; 57:583-7. [PMID: 12665777 DOI: 10.1067/mge.2003.142] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Local endoscopic mucosal resection of rectal carcinoid tumors is often associated with margin involvement that requires further intervention. The efficacy of resection of these tumors with endoscopic submucosal resection with a ligation device (ESMR-L) was evaluated. METHODS Fourteen rectal carcinoid tumors were treated by ESMR-L between 1999 and 2002. ESMR-L was performed with a conventional colonoscope with an attached band-ligator device. For comparison, 14 rectal carcinoid tumors, treated by either endoscopic mucosal resection or polypectomy between 1990 and 1997, were evaluated as historical controls. All tumors were estimated to be 1 cm or less in diameter. OBSERVATIONS There were no differences between the 2 groups in terms of age, gender, or tumor size. For 6 (43%) patients in the control group, there was tumor involvement at the margin of the resection specimen, whereas all tumors removed by ESMR-L had histopathologically proven negative margins (p < 0.05). The mean vertical resection margin also was significantly deeper in the ESMR-L group (p < 0.05). There was no complication of any procedure. CONCLUSIONS ESMR-L is technically simple, minimally invasive, and safe for treatment of small rectal carcinoid tumors contained within the submucosa. ESMR-L provides a deeper resection margin compared with that obtained with conventional endoscopic mucosal resection or polypectomy.
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Affiliation(s)
- Akiko Ono
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital, Tokyo, Japan
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Abstract
Barrett's esophagus consists of a precancerous condition in which the progression from dysplasia to adenocarcinoma is now well documented. The management of patients affected by Barrett's esophagus is still debatable, in particular for the risk of surgical treatment in the presence of small precancerous lesions or early adenocarcinoma. Furthermore, quality of life after surgical resection is often poor. Endoscopy is the main diagnostic and follow-up procedure in Barrett's esophagus: it allows the detection and treatment of severe dysplasia and invasive esophageal adenocarcinoma. Endoscopic treatment also produces reduction or disappearance of intestinal metaplasia. In these cases, the aim of the treatment is to prevent dysplastic changes. Moreover, the ideal endoscopic treatment should be safe, easy to perform and cost effective. Thermal (electrocoagulation, laser, argon-plasma coagulation), photochemical (photodynamic therapy) or ablative (endoscopic mucosal resection) procedures have been proposed alone or in combination, with the aim to completely eradicate dysplastic lesions or early adenocarcinoma as an alternative to surgical treatment. Endoscopic removal of the lesions is followed by restoration of normal epithelium. Some questions about patient selection, prevention of recurrence and best endoscopic treatment still remain unanswered.
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Affiliation(s)
- Pasquale Spinelli
- Diagnostic and Surgical Endoscopy Unit, National Cancer Institute, Milan, Italy
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Feitoza AB, Gostout CJ, Burgart LJ, Burkert A, Herman LJ, Rajan E. Hydroxypropyl methylcellulose: A better submucosal fluid cushion for endoscopic mucosal resection. Gastrointest Endosc 2003; 57:41-7. [PMID: 12518129 DOI: 10.1067/mge.2003.25] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Formation of a submucosal fluid cushion has become integral to endoscopic mucosal and polyp resection. Solutions available for injection into the submucosa of the GI tract create short-lasting submucosal fluid cushions or are costly. The feasibility, durability, and histologic response to submucosal fluid cushions created by injection of hydroxypropyl methylcellulose were studied in the esophagus of pigs. METHODS Thirty-six esophageal submucosal fluid cushions created with hydroxypropyl methylcellulose were studied in 12 animals divided in 2 groups of 6 animals each. In Group I, 18 submucosal fluid cushions were created by submucosal injection of hydroxypropyl methylcellulose followed by tattooing. In Group II, 18 submucosal fluid cushions were created by submucosal injection of hydroxypropyl methylcellulose, with sites marked by an endoscopically placed suture. In all cases, the duration of the submucosal fluid cushion was measured. After 7 days, submucosal fluid cushion sites were assessed by EGD, necropsy, and histologic evaluation. RESULTS The mean submucosal fluid cushion duration was 36 minutes (3-45 minutes) and 38 minutes (5-45 minutes) for, respectively, Groups I and II. EGD and necropsy after 1 week showed normal-appearing mucosa at the site of all submucosal fluid cushions in both groups. Some Group I animals additionally had nodules at the tattoo sites. Histologic assessment demonstrated minimal alterations in 33 of 36 (92%) submucosal fluid cushion sites and localized mild inflammatory reaction in 3 of 36 (8%). In Group I, 8 of 18 (44%) tattoo sites exhibited a significant inflammatory reaction, including 3 abscesses. CONCLUSIONS Hydroxypropyl methylcellulose creates a long-lasting submucosal fluid cushion with minimal tissue reaction and should be considered a low-cost option for creating submucosal fluid cushions. The use of tattooing with carbon black should be carefully considered when histologic study is required to assess potential inflammatory tissue responses to an invasive technique or instillation of foreign material in the GI tract.
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Affiliation(s)
- Arnaldo B Feitoza
- Developmental Endoscopy Unit, Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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Conio M, Rajan E, Sorbi D, Norton I, Herman L, Filiberti R, Gostout CJ. Comparative performance in the porcine esophagus of different solutions used for submucosal injection. Gastrointest Endosc 2002. [PMID: 12297766 DOI: 10.1016/s0016-5107(02)70435-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Before endoscopic mucosal resection and polypectomy of sessile lesions, injection of fluid into the submucosa cushions and isolates the tissue and thereby reduces thermal injury and the risk for perforation and hemorrhage. This study investigated the performance of 5 different solutions when used to form submucosal fluid cushions in the porcine esophagus. METHODS Five groups of 5 pigs were studied. In each pig, 6 separate submucosal injections of 5 mL of a single test solution were performed within the distal third of the esophagus. The time required for the submucosal bleb to flatten completely was recorded after each injection. The solutions used were as follows: normal saline solution, normal saline plus epinephrine solution, 50% dextrose, 10% glycerine/5% fructose in normal saline solution, and 1% rooster comb hyaluronic acid. RESULTS The normal saline solution and normal saline plus epinephrine solutions had the shortest disappearance times (respectively, median 2.4 and 3.0 minutes), which were significantly shorter compared with the other test solutions. The mean disappearance times for 50% dextrose and 10% glycerine were, respectively, 4.7 and 4.2 minutes. The mean disappearance time for hyaluronic acid was 22.1 minutes. CONCLUSIONS A solution of hyaluronic acid appears to be ideal for producing a lasting submucosal cushion for prolonged procedures. Dextrose 50% is superior to normal saline solution and may serve as an alternative to hyaluronic acid in terms of availability and cost.
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Affiliation(s)
- Massimo Conio
- Developmental Endoscopy Unit, Center for Endoscopic Research and Development, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
Better outcomes for digestive tract cancers are likely to be possible if the tumors are detected in their earliest stages, particularly when they exist as mucosal lesions without lymph node metastases. Early esophageal squamous cell cancers can be detected with high sensitivity and specificity by iodine staining. Only mucosal cancers are suitable for the curative approach of submucosal resection; the rate of metastasis is 4%, compared to a rate of metastasis of 35% in tumors with submucosal spread. In this review, the history of endscopic mucosal resection is reviewed, including the factors that have refined the technique and technical aspects crucial for effective results. The importance of adequate submucosal injection of dilute epinephrine in saline solution is particularly emphasized. The overall efficacy, low rate of complications and such practical aspects as post-therapeutic care are discussed. In general, mucosal cancers of the gastrointestinal tract have no risk of lymph node metastases and can be curatively managed by refined endoscopic mucosal resection procedures.
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Affiliation(s)
- Haruhiro Inoue
- Digestive Disease Center, Northern Yokohama Hospital, Showa University, Chuo 35-1, Chigasaki, Tzusuki-ku, Yokohama 224-8503, Japan.
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Waxman I. Endosonography-assisted endoscopic mucosal resection of submucosal tumors of the gastrointestinal tract. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2002. [DOI: 10.1053/tgie.2002.31950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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40
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Inoue H, Fujimoto M, Fukami N, Yoshida T, Kudo SE. Endoscopic mucosal resection for esophageal cancer. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2002. [DOI: 10.1053/tgie.2002.31953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Waxman I, Saitoh Y, Raju GS, Watari J, Yokota K, Reeves AL, Kohgo Y. High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract. Gastrointest Endosc 2002; 55:44-9. [PMID: 11756913 DOI: 10.1067/mge.2002.119871] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy and safety of high-frequency probe EUS (HFPE)-assisted endoscopic mucosal resection in the management of submucosal tumors of the GI tract. METHODS HFPE-assisted endoscopic mucosal resection was attempted in 28 patients with submucosal tumors less than 2 cm in diameter. HFPE was performed with a 20-MHz "through-the-scope" probe. Saline solution was injected into the submucosa. After confirming detachment of the lesion from the muscularis propria by repeat HFPE, endoscopic mucosal resection was performed with a lift-and-cut or endoscopic mucosal resection cap technique. Follow-up endoscopy was performed in all patients. RESULTS Submucosal tumors from the following areas were included: esophagus 3, stomach 4, duodenum 3, and colon 18. The submucosal tumors were located in the upper third (n = 3), middle third (n = 18), and lower third (n = 7) of the submucosa. Twenty-one submucosal tumors were removed by the lift-and-cut technique and 6 by the cap method. One patient required surgical resection after unsuccessful endoscopic mucosal resection. The origin and depth of penetration of all lesions was accurately depicted by HFPE. Median tumor diameter was 9 mm (range 3-20 mm). Resection was successful and complete in 93% of the cases. There were no immediate postprocedure complications (exact 95% CI [0%, 12.3%]). During a median follow-up of 21.5 months (range 2-74 months) no recurrence was found. CONCLUSIONS HFPE-assisted endoscopic mucosal resection is safe and effective for the management of selected submucosal tumors of the GI tract. A management algorithm based on endoscopic and HFPE findings is proposed.
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Affiliation(s)
- Irving Waxman
- University of Texas Medical Branch at Galveston, Texas, USA
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Rollins AM, Sivak MV. Potential new endoscopic techniques for the earlier diagnosis of pre-malignancy. Best Pract Res Clin Gastroenterol 2001; 15:227-47. [PMID: 11355913 DOI: 10.1053/bega.2000.0171] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Light interacts with tissue in a variety of ways, including absorption, fluorescence, elastic scattering and Raman scattering. These interactions enable a number of promising technologies for endoscopic diagnosis of pre-malignancy, including chromoscopy; fluorescence, scattering and Raman spectroscopies; and optical coherence tomography. Although still in various stages of technical development and clinical trials, these optical diagnostic techniques are demonstrating strong potential to significantly enhance the clinical endoscopist's ability to detect dysplasia in gastrointestinal mucosae.
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Affiliation(s)
- A M Rollins
- Division of Gastroenterology, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
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Affiliation(s)
- P R Pfau
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio 44106, USA
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Nelson DB, Block KP, Bosco JJ, Burdick JS, Curtis WD, Faigel DO, Greenwald DA, Kelsey PB, Rajan E, Slivka A, Smith P, Wassef W, Vandam J, Wang KK. Endoscopic mucosal resection: May 2000. Gastrointest Endosc 2000; 52:860-863. [PMID: 11182691 DOI: 10.1016/s0016-5107(00)70224-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Affiliation(s)
- G S Raju
- Kansas University Medical Center, Kansas City, Kansas, USA
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Abstract
Recent advances in endoscopic mucosal resection of superficial early digestive tract cancers are truly remarkable. The extraordinary long-term outcomes of patients who have been treated with endoscopic mucosal resection have encouraged the widespread practice of endoscopic mucosal resection in Japan. These minimally invasive techniques allow safe and effective treatment of diseases that would otherwise require major surgery. This article provides an overview of endoscopic mucosal resection techniques, their associated outcomes, and other potential applications of endoscopic mucosal resection.
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Affiliation(s)
- R M Soetikno
- Gastroenterology Section, Veterans Affairs Palo Alto Health Care System, California, USA.
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Nijhawan PK, Wang KK. Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett's esophagus. Gastrointest Endosc 2000; 52:328-32. [PMID: 10968845 DOI: 10.1067/mge.2000.105777] [Citation(s) in RCA: 206] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic mucosal resection has been used in the treatment of superficial squamous cell cancers and gastric malignancies. Our aim was to determine whether endoscopic mucosal resection can be used in the diagnosis of lesions within Barrett's esophagus whose endoscopic appearances raise suspicion of carcinoma or high-grade dysplasia. METHODS Twenty-five patients with such lesions within Barrett's esophagus underwent endoscopic mucosal resection for diagnostic and therapeutic purposes. All patients underwent endoscopic ultrasound to determine the feasibility of endoscopic resection. Only lesions found to be uT0 or uT1 underwent EMR. The lift and cut technique was used in 23 patients and a variceal ligating device was used on 2 patients. RESULTS Endoscopic mucosal resection was performed because of a nodule or polyp within Barrett's esophagus in 11 patients (44%) and suspected superficial cancer or high-grade dysplasia in 14 patients (56%). Endoscopic mucosal resection diagnosed superficial adenocarcinoma in 13 patients (52%) and high-grade dysplasia in 4 (16%); it confirmed lesions in 8 patients (40%) to be of lower neoplastic risk. No complications occurred due to the procedure itself. CONCLUSIONS Endoscopic mucosal resection is a technique with low morbidity and mortality. It has led to a change in diagnosis in patients with Barrett's esophagus and lesions with endoscopic features that suggest neoplasia. Its major advantages include simplicity and retrieval of the specimen en bloc.
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Affiliation(s)
- P K Nijhawan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Koyama N, Yosida H, Sakonji M, Takebuchi K, Muto Y, Watanabe M, Wachi E. Endoscopic Resection Using a Ligating Device for Esophageal Granular Cell Tumors: A Report of Two Cases. Dig Endosc 2000. [DOI: 10.1046/j.1443-1661.2000.00050.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Nobuatsu Koyama
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
| | - Hatsuo Yosida
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
| | - Mitsuaki Sakonji
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
| | - Kazuhiro Takebuchi
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
| | - Yoshiki Muto
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
| | - Mitsuyuki Watanabe
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
| | - Eiko Wachi
- *Department of Surgery, **Department of Internal Medicine and † Pathology Jizankai Medical Foundation Tsuboi Hospital, Fukushima, Japan
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Lambert R. Endoscopic mucosectomy: an alternative treatment for superficial esophageal cancer. Recent Results Cancer Res 2000; 155:183-92. [PMID: 10693252 DOI: 10.1007/978-3-642-59600-1_19] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Recent trends in the management of superficial esophageal cancer consist of improved detection, pretherapeutic staging and reliable criteria for curative endoscopic therapy. The endoscopic treatment is legitimate when the cancer is at an early stage, intra-epithelial or microinvasive (m1 or m2) and N0. Submucosal cancer should not be treated with a curative intent by endotherapy. Concerning squamous cell cancer, the oriental and occidental pathologists include high-grade dysplasia in the same group as intramucosal cancer. The distinction is however maintained for adenocarcinoma in the Barrett's esophagus. Indications of endoscopic rather than surgical treatment rely on: (1) the small size of the tumor (not more than 2 cm in diameter); (2) the endoscopic morphology in the type 0 of the Japanese classification with the flat subtypes IIa and IIb rather than type IIc--there is high risk of submucosal invasion for the polypoid (type I) or ulcerated superficial cancer (type III); and (3) the endoscopic ultrasound staging, with confirmed integrity of the hyperechoic submucosal layer. The high-frequency (20 MHz) miniprobe is preferred to the standard (7.5 MHz) instrument. The elective procedure for tumor eradication is endoscopic mucosectomy. The technique is associated with a 6.8% risk of severe complications (hemorrhage or perforation) and a recurrence rate of 3%-7%. The 5-year survival rate is similar to that of surgery (over 80%). In the small group of patients with superficial esophageal cancer (less than 10% of the disease) endoscopic treatment may now be proposed in about 30% of cases, surgery is preferred for submucosal cancer and for neoplasia with a large surface. Areas of high-grade dysplasia in the Barrett's esophagus offer a new and increasing sector of indications. The concurrent endoscopic procedure of destruction--photodynamic therapy--is preferred for the destruction of lesions with poorly delineated limits.
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Affiliation(s)
- R Lambert
- Department of Digestive Diseases, Hospital Edouard Herriot, Lyon, France
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Maiss J, Hahn EG, Hochberger J. TECHNIKEN DER ENDOSKOPISCHEN MUKOSARESEKTION BEI PRÄMALIGNEN UND MALIGNEN LÄSIONEN IM MAGEN. BIOMED ENG-BIOMED TE 2000. [DOI: 10.1515/bmte.2000.45.s1.549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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