Successful en bloc resection of superficial esophageal cancer treated by endoscopic submucosal dissection with a splash needle

Animal feasibility study of an innovated splash-needle for endoscopic submucosal dissection in the upper gastrointestinal tract

BACKGROUND AND AIM

The high frequency of complications accompanying endoscopic submucosal dissection (ESD) and its complex processes suggest that the process requires improvement. The objective of the present study was to investigate the feasibility of an innovated splash-needle for ESD.

METHODS

An animal feasibility study with a living pig was conducted. Six resections per portion (esophagus and upper, middle, and lower thirds of the stomach) in a total of 24 resections were carried out by using an original splash-needle or an innovated splash-needle. Major innovations were a thicker part in the middle of the knife and a metal plate on the tip of the sheath to obtain more coagulation ability. Injection solution in the submucosal layer was also changed due to possible influence on the outcomes. Main outcome measurements were entire procedure time, cutting speed, and frequency of bleeding during ESD.

RESULTS

All the 24 resections were completed without complications. Among the obtained data, only mean cutting speeds were significantly influenced by location of the simulated lesion, which revealed that ESD at the upper third was significantly quicker than that at the lower third (P = 0.01), and ESD at the esophagus was significantly slower than that at the three parts of the stomach (P < 0.01). There was no significant difference between the different knives in each variable.

CONCLUSIONS

The innovated splash-needle will be feasible for human use, although the safety and advantages in clinical settings must be elucidated by proper comparative studies with existing knives in humans.

[Endoscopic submucosal dissection in our practice -- new possibilities in the endoscopic treatment of neoplastic changes in the alimentary canal]

Endoscopic submucosal dissection is a promising new endoscopic technique for en block resection of early, superficial, flat, and laterally spreading gastrointestinal neoplasms. The primary aims of this prospective study were to summarize the first Hungarian experience with endoscopic submucosal dissection, and to compare the experimental in vivo procedures in pigs with the human application of this technique in two academic centers.

METHODS

The ex vivo Erlangen pig model was used until initial competence was achieved. Thereafter 15 endoscopic submucosal dissection procedures were performed in up to 5 sessions in living pigs under general anesthesia. After submucosal injection with saline Fujinone ball tip, a Flush knife was used with a transparent hood for circumferential incision and submucosal dissection. The following variables were analyzed: specimen size, complete and en bloc resection rate, total duration of the procedure, and complications. Furthermore, between 2009 and 2012, 14 endoscopic submucosal dissections were carried out in humans; 1 duodenal, 3 gastric and 10 colorectal interventions were performed due to large laterally spreading intramucosal neoplasms. The specimen size, en bloc resection rate, total duration of the procedure and complications were next analyzed.

RESULTS

87% complete resection rate, 29.4 ± 19.5 cm2 specimen size and 136.2 ± 26.8 min of procedure duration were achieved in the live pig models. Nontransmural damages of the muscular layer occurred in 3/15 (20%) cases which were successfully closed with hemoclips, except in one pig that died due to fatal esophageal perforation. All bleedings were easily managed with hot biopsy forceps coagulation and hemoclips without hemodynamic instability. In humans, endoscopic submucosal dissection was accomplished with an 11/14 (79%) en block resection rate, with average resected specimen size of 11.56 ± 4.9 cm2 and with 157 ± 55 min of operating time. Two cases of bleeding and 2 cases of perforation occurred (14%), all of which were managed endoscopically. After 1.5 year of average follow up, local recurrence occurred in one case only. In addition, due to the 3 incomplete resections and unsuccessful endoscopic submucosal dissection, surgical intervention was required in 4 cases altogether.

CONCLUSIONS

This study demonstrates the first Hungarian experience with endoscopic submucosal dissection. Training in live pig models could help endoscopists to overcome the learning curve and minimize the risk of complications before starting the procedure in humans. Reduction in the resection time and low risk of complications, especially bleeding, could be achieved by the application of a flush knife.

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.

Endoscopic treatment for early gastric cancer

Endoscopic resection has been accepted as a curative modality for early gastric cancer (EGC). Since conventional endoscopic mucosal resection (EMR) has been introduced, many improvements in endoscopic accessories and techniques have been achieved. Recently, endoscopic submucosal dissection (ESD) using various electrosurgical knives has been performed for complete resection of EGC and enables complete resection of EGC, which is difficult to completely resect in the era of conventional EMR. Currently, ESD is accepted as the standard method for endoscopic resection of EGC in indicated cases. In this review, the history of endoscopic treatment for EGC, overall ESD procedures, and indications and clinical results of endoscopic treatment will be presented.

Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients

OBJECTIVES

Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC).

METHODS

A query of PubMed, MEDLINE, Embase and Cochrane Library (1980-2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled patients with submucosal esophageal cancer and provided adequate extractable data were included.

RESULTS

The pooled outcomes of 7645 patients with esophageal cancer involving the sm level of infiltration were included in the analysis. Overall, the percentage of lymph node metastasis in submucosal cancer was 37%. Lymph node (N), lymphatic (L) and vascular (V) invasion in sm1 esophageal cancers was 27, 46 and 22%, respectively. Within sm2 lesions, N, L and V invasion were involved in 38, 63 and 38% of patients, respectively. Finally, N, L and V involvement in patients with sm3 lesions was 54, 69 and 47%, respectively. The rates of lymph node metastasis for sm1 and sm2 were higher in SCC compared with ADC, whereas the lymph node metastasis for sm3 was comparable, with >50% involvement in both histologic subtypes. SCC revealed an overall more aggressive behavior compared with ADC (N+: 45 vs 26%; L+: 57 vs 37%; V+: 40 vs 18%).

DISCUSSION

While endoscopic therapy may be adequate in selected patients with 'low-risk' sm1 ADC, submucosal SCC necessitates esophageal resection and systematic lymphadenectomy because of its aggressive nature and tendency for early metastasis.

Endoscopic submucosal dissection for esophageal squamous cell neoplasms

Endoscopic submucosal dissection (ESD) has gradually gained acceptance as one of the standard treatments for early esophageal cancer, as well as for early gastric cancer in Japan, but standardization of the knowledge is still incomplete. The final goal to perform ESD is not to resect the lesion in an en bloc fashion, but to save the patient from esophageal cancer-related death. Thus, the indications should be considered based on the entire patient, not just the target lesion itself, and pre-, peri- and postoperative management of the patient is also very important, as well as technical aspects of ESD. In terms of the techniques of ESD, owing to refinement of the procedural strategy, invention of the devices, and the learning curve, acceptable safety and favorable middle-term efficacy have been obtained. We believe that ESD will become a standard treatment for early esophageal cancer not only in Japan but also worldwide in the near future.

Endoscopic submucosal dissection for gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy for superficial gastrointestinal neoplasms. Three steps characterize it: injecting fluid into the submucosa to elevate the lesion, cutting the surrounding mucosa of the lesion, and dissecting the submucosa beneath the lesion. The ESD technique has rapidly permeated in Japan for treatment of early gastric cancer, due to its excellent results of en-bloc resection compared to endoscopic mucosal resection (EMR). Although there is still room for improvement to lessen its technical difficulty, ESD has recently been applied to esophageal and colorectal neoplasms. Favorable short-term results have been reported, but the application of ESD should be well considered by three aspects: (1) the possibility of nodal metastases of the lesion, (2) technical difficulty such as location, ulceration and operator’s skill, and (3) organ characteristics.