A modified technique for endoscopic mucosal resection of small early gastric carcinomas

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.

Efficacy and safety of 0.4 percent sodium hyaluronate for endoscopic submucosal dissection of gastric neoplasms

AIM: To evaluate the efficacy and safety of sodium hyaluronate solution (SH) in endoscopic submucosal dissection (ESD) of gastric neoplasms.

METHODS: A prospective multicenter randomized, double blind, controlled trial was designed and utilized in this study. A total of 76 patients with 5-20 mm sized gastric neoplasms were enrolled at three academic hospitals in South Korea from June 2011 to October 2011. Patients were randomly assigned to the 0.4% sodium hyaluronate or control groups. All lesions underwent endoscopic ESD. ESD was performed with 0.4%SH and normal saline (NS) solution for submucosal injection. Efficacy was assessed using en bloc resection and the number of additional injections. Secondary evaluation variables were the volume of injection material, steepness of mucosal elevation, bleeding rate, procedural time and operator satisfaction. Finally, the safety was assessed by analyzing adverse events during the study.

RESULTS: The usefulness rate in the 0.4%SH group and the controlled group had statistically significant difference under intention to treat (ITT) analysis (90.91% vs 61.11% P = 0.0041). Under per protocol (PP), the usefulness rate is statistically significant different (93.10% vs 61.76%, P = 0.0036). The difference in volume of the solution injected between 0.4%SH group and the controlled group and NS group was also statistically significant under intention to treat and per protocol analysis (ITT: 0.03 ± 0.02 mL vs 0.06 ± 0.03 mL, P = 0.0003, PP: 0.03 ± 0.02 mL vs 0.06 ± 0.03 mL, P = 0.0004). Satisfaction above the grade good was significantly higher in the SH group under intention to treat and per protocol analysis (ITT: 90.91% vs 61.11%, P = 0.0041, PP = 93.11% vs 61.77%, P = 0.0022). Adverse events above grade 3 were not noticed in either group. All adverse events were treated and were judged as not associated with the submucosal injection solutions.

CONCLUSION: 0.4%SH solution is a safe and effective agent that doesn’t cause any significant adverse events and is useful for submucosal injection during ESD.

Design and planned analyses of an ongoing randomized trial assessing the preventive effect of Helicobacter pylori eradication on occurrence of new gastric carcinomas after endoscopic resection

BACKGROUND

A causal relationship between Helicobacter pylori infection and gastric cancer has been established. A nonrandomized study has shown eradication of H. pylori after endoscopic resection (ER) of early gastric cancer inhibits development of new carcinomas.

SUBJECTS AND METHODS

Eligible subjects are patients with H. pylori infection who are newly diagnosed with early gastric cancer and plan to have ER or who are in the post-resection follow-up phase after ER time of enrollment. Patients are randomly allocated to the eradication or the control arms (no eradication and standard of care). Patients will be evaluated by endoscopy at 0.5, 1, 2, and 3 years after randomization. Diagnosis of a new carcinoma at another site of the stomach is defined as primary endpoint, and recurrence of tumors at the resection site as a secondary endpoint. In addition to intention-to-treat and per-protocol analyses using proportional hazards models, time to recurrence will be compared between treatment and control using multiple logistic regression analyses. In the latter two situations, the models will be adjusted for the factors exerting significant influences on the results.

RESULTS

Five hundred and forty-two subjects have been enrolled into the study and are being followed-up.

CONCLUSIONS

This study will have the statistical power to demonstrate whether H. pylori eradication therapy exerts any clinically relevant inhibitory effects on occurrence or recurrence of gastric cancer. In addition, it will be able to test the hypothesis that H. pylori infection is a promoter in gastric carcinogenesis.

Endoscopic mucosal resection for early gastric cancer

BACKGROUND

The treatment of early gastric cancer (EGC) using an endoscopy, namely, endoscopic mucosal resection (EMR), has been adopted for about 20 years, but the effectiveness and the safety of the modality are still controversial. The quality of these trials has not been assessed systematically.

OBJECTIVES

The purpose of this review was to compare the effectiveness and the safety of EMR with gastrectomy for the treatment of EGC.

SEARCH STRATEGY

Searches were conducted on the Cochrane Central Register of Controlled Trials - CENTRAL (which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register) on The Cochrane Library (Issue 1 2005) MEDLINE (1966 to March 2005) and EMBASE (1980 to March 2005), CINAHL (1985-March 2005) and CBM (Chinese BioMedical Database 1982 -2002). Reference lists from trials selected by electronic searching were handsearched to identify further relevant trials. Published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology) were handsearched. Members of the Cochrane UGPD Group, and experts in the field were contacted and asked to provide details of outstanding clinical trials and any relevant unpublished materials

SELECTION CRITERIA

All randomised controlled trials of EGC patients involving a treatment arm of EMR and a comparison arm of gastrectomy were to be included, but no RCTs were found.

DATA COLLECTION AND ANALYSIS

Three reviewers (YP Wang, C Bennett and T Pan) independently assessed the eligibility of potential trials and extracted the data.

MAIN RESULTS

There are no included randomised control trials for the systematic review. Available evidence derived from non-randomised controlled trials is discussed in the main text of this review.

AUTHORS' CONCLUSIONS

There is a lack of randomised controlled trials in which EMR is compared with gastrectomy for EGC. There is a need for well designed randomised controlled trials to determine the effects of EMR compared to gastrectomy.

Endoscopic therapy of lower gastrointestinal cancer

Since the 1960's, endoscopy has revolutionised the practice of gastroenterology. Although initially diagnostic, endoscopy is now playing an increasingly therapeutic role. There are many reasons to believe that therapeutic endoscopy will shape the practice of gastroenterology further in the future. Only a few years ago we relied on low-resolution fibreoptic endoscopes. Nowadays even standard equipment allows the mucosa to be scrutinised in great detail. Dedicated training in endoscopy together with attention to quality indicators such as polyp detection and caecal intubation rates will ensure that fewer early gastrointestinal cancers are missed in the future. Open access endoscopy and screening programs are being introduced in many Western countries which will also lead to more lesions being detected in their early stages. This chapter discusses the main issues surrounding the endoscopic therapy of lower gastrointestinal cancers.

Endoscopic mucosal resection with a cap-fitted endoscope versus freehand gastric mucosectomy in an animal model

BACKGROUND

Endoscopic mucosal resection with a cap-fitted endoscope appears to be as effective but easier to perform than freehand mucosectomy. However, experience with this technique has been limited to small case series and there is a lack of data from direct comparison trials.

METHODS

Nine pigs were randomized to mucosectomy using a cap-fitted endoscope or the freehand technique. Five mucosal resections were performed at five different sites in the gastric body in each pig. Eight to ten milliliters of a saline, epinephrine, and methylene blue solution were injected to raise a bleb to simulate a mucosal lesion. Endoscopic mucosal resection with a cap-fitted endoscope was performed by suctioning the bleb into the cap device pre-looped with an oval snare; mucosectomy was performed electrosurgically. Freehand mucosectomy was performed by encircling and then resecting the bleb using an oval snare. The ease of procedure (1 = "very easy" to 5 = "unable to complete") was assessed after each resection. The animals were recovered, maintained, and then humanely sacrificed after 2 weeks.

RESULTS

Five pigs underwent endoscopic mucosal resection with a cap-fitted endoscope and 4 underwent freehand mucosectomy. Eight animals survived for 2 weeks without complications and one animal from the freehand group died of massive hemorrhage within 48 hours of endoscopy. Both methods produced rounded resection specimens measuring 9 to 12 mm in diameter of the full thickness of the mucosa and the submucosa. Overall ease of resection was 1.84 +/- 0.52 for the cap-fitted group and 2.98 +/- 0.86 for the freehand group (p < 0.0001). All of the sites identified at autopsy were completely re-epithelialized, except for the five sites found in the pig that died prematurely.

CONCLUSIONS

Endoscopic mucosal resection with a cap-fitted endoscope is as effective, safe, but easier to perform compared with freehand mucosectomy.

A novel method of endoscopic mucosal resection using sodium hyaluronate

BACKGROUND

Saline-assisted endoscopic mucosal resection is an established therapeutic method. However, it is sometimes difficult to maintain a desired level of tissue elevation after injection of saline. Therefore we decided to use a mucinous substance such as sodium hyaluronate instead of saline.

METHODS

Two resected porcine stomachs and five dogs were used for the study. The elevations, made by submucosal injections of sodium hyaluronate, were compared with those produced with normal saline. Sodium hyaluronate-assisted mucosal resections were compared with the saline-assisted resections.

RESULTS

Mucosal elevations created by submucosal injections of sodium hyaluronate remained for a longer time with a clearer margin compared to those made by saline injection. Endoscopic mucosal resections were performed safely with the assistance of sodium hyaluronate.

CONCLUSIONS

Use of sodium hyaluronate instead of saline for endoscopic mucosal resection could make the procedure easier and more reliable.