Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.
Thirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.
The mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7 %) were movable, and 15 (45.7 %) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60 %) and gastrointestinal stromal tumor (28.6 %). The complete resection rate was 74.3 %. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).
The ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.
Subepithelial tumor; Muscularis propria; Endoscopic submucosal dissection
Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.
endoscopic submuscosal dissection; gastric fundus; muscularis propria
Endoscopic submucosal dissection (ESD) is a new endoluminal therapeutic technique involving the use of cutting devices to permit a larger resection of the tissue over the muscularis propria. The major advantages of the technique in comparison with polypectomy and endoscopic mucosal resection are controllable resection size and shape and en bloc resection of a large lesion or a lesion with ulcerative findings. This technique is applied for the endoscopic treatment of epithelial neoplasms in the gastrointestinal tract from the pharynx to the rectum. Furthermore, some carcinoids and submucosal tumors in the gastrointestinal tract are treated by ESD. To determine the indication, two aspects should be considered. The first is a little likelihood of lymph node metastasis and the second is the technical resectability. In this review, practical guidelines of ESD for the gastrointestinal neoplasms are discussed based on the evidence found in the literature.
Endoscopic submucosal dissection; Endoscopic mucosal resection; Gastrointestinal neoplasm; Treatment guideline; Lymph node metastasis
Ligation-assisted endoscopic enucleation (EE-L) was developed for the pathological diagnosis and resection of small gastrointestinal tumors originating from the muscularis propria. The technique combines endoscopic band ligation and endoscopic enucleation. The aim of this study was to evaluate the efficacy and safety of EE-L in the diagnosis and resection of gastrointestinal tumors originating from the muscularis propria.
A total of 43 patients were eligible for inclusion in this study from June 2009 to June 2011. Endoscopic ligation was first performed to force the tumor to assume a polypoid form with a pseudostalk. EE-L was then performed until the tumor was completely enucleated from the muscularis propria. Wound closure was performed using clips and adhesive tissue.
All 43 tumors were completely enucleated. The mean enucleation time was 7.2 minutes (range, 5–11 minutes). No perforation, massive hemorrhage, or peritonitis requiring further endoscopic or surgical intervention occurred. Histopathology, 19 lesions were identified as gastrointestinal stromal tumors and 24 lesions were identified as leiomyomas. The mean follow-up time was 20.4 months (range, 14–38 months). No recurrence has occurred during the follow-up period.
EE-L appears to be a safe, effective, and relatively simple method for the histologic diagnosis and removal of small gastrointestinal tumors originating from the muscularis propria.
Endoscopic resection; Ligation; Subepithelial tumor; Muscularis propria
AIM: To explore endoscopic therapy methods for gastric stromal tumors originating from the muscularis propria.
METHODS: For 69 cases diagnosed as gastric stromal tumors originating from the muscularis propria, three types of endoscopic therapy were selected, based on the size of the tumor. These methods included endoscopic ligation and resection (ELR), endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFR). The wound surface and the perforation of the gastric wall were closed with metal clips. Immunohistostaining for CD34, CD117, Dog-1, S-100 and smooth muscle actin (SMA) was performed on the resected tumors.
RESULTS: A total of 38 cases in which the tumor size was less than 1.2 cm were treated with ELR; three cases were complicated by perforation, and the perforations were closed with metal clips. Additionally, 18 cases in which the tumor size was more than 1.5 cm were treated with ESE, and no perforation occurred. Finally, 13 cases in which the tumor size was more than 2.0 cm were treated with EFR; all of the cases were complicated by artificial perforation, and all of the perforations were closed with metal clips. All of the 69 cases recovered with medical treatment, and none required surgical operation. Immunohistostaining demonstrated that among all of the 69 gastric stromal tumors diagnosed by gastroscopy, 12 cases were gastric leiomyomas (SMA-positive), and the other 57 cases were gastric stromal tumors.
CONCLUSION: Gastric stromal tumors originating from the muscularis propria can be treated successfully with endoscopic techniques, which could replace certain surgical operations and should be considered for further application.
Gastrointestinal stromal tumors; Therapy; Endoscopy; Muscularis propria; Resection
Endoscopic submucosal dissection (ESD) is the most advanced and representative technique in the field of therapeutic endoscopy and has been used for the treatment of gastrointestinal neoplasms, including early gastric cancer. The major difference and advantage of ESD compared to existing endoscopic resection techniques, such as endoscopic mucosal resection (EMR) and polypectomy, are the width and depth of the resection. Newly developed cutting devices, distal attachable endoscopic accessories, and an advanced electrosurgical unit have helped to overcome the limitations of therapeutic endoscopy in terms of lesion size, location, presence of fibrotic scarring, and accompanying ulcers. As a result, the indications for ESD have been expanded from the classical indication for EMR and polypectomy, and there is now support for a further expansion of ESD indications. At present, the most critical factor to consider in the decision of whether to perform ESD is the probability of unexpected lymph node metastasis. The guidelines for ESD are continually being updated and debated. In this review, we discuss the strengths and weaknesses of the expanded guidelines, based on evidence found in the literature.
Endoscopic submucosal dissection; Endoscopic mucosal resection; Early gastric cancer; Indications
Endoscopic submucosal dissection (ESD) has the advantage over endoscopic mucosa resection, permitting removal of gastrointestinal neoplasms en bloc, but is associated with relatively high risk of complications. Indications for early gastric cancer (EGC) are expanded: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ≤3 cm in diameter; and minute submucosal invasive cancer ≤3 cm in size. The indications for early esophageal cancer (EEC) are the tumors confined to the two-third layer of the lamina propria. The EEC lesions spreading more than three-quarter of circumference of the esophagus are at frequent risk of stenosis. The procedures include marking, submucosal injection, circumferential mucosal incision and exforiation of the lesion along the submucosal layer. Complete ESD can achieve a large one-piece resection, allowing precise histological assessment to prevent recurrence. Clinical outcomes of gastric and esophageal ESD have been promising, and the prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted. Notification of perforation risk is essential in particular for esophageal ESD. Bleeding during ESD can be managed with coagulation forceps, and postoperative bleeding may be reduced with routine use of the stronger acid suppressant, proton pump inhibitors.
endoscopic submucosal dissection; proton pump inhibitor; early gastric cancer; early esophageal cancer; Barrett’s adenocarcinoma
Endoscopic submucosal (sm) dissection (ESD) is a recently used technique that enables en-bloc resection of large colorectal tumors allowing a more precise histopathological analysis of the resected specimen. However, it has not been widely adopted even in Japan mainly due to its technical difficulty and increased risk of perforation. Herein, we present an ESD-treated lesion with deep sm invasion removed without complications, such as bleeding or perforation, from a patient at high-risk for surgical intervention. A successful ESD was achieved although the sm invasion was greater than 1000 μm from the muscularis mucosae, and the nonlifting sign was positive. It is our belief that this procedure should be performed at least in patients at high-risk for surgical intervention. At present, we have removed 16 lesions with deep sm invasion by ESD without complications, demonstrating that deep sm cancer can be successfully resected by this technique as a local resection. Herein, we report on one of these cases.
Metastatic gastric cancer is extremely rare and gastric metastasis from ovarian adenocarcinoma has rarely been reported. All of the previously reported metastatic lesions presented as an ulcerative lesions. We report a case of 49-year-old woman in which gastric metastasis from ovarian adenocarcinoma presented as a submucosal tumor without ulceration on endoscopic examination. Gastrointestinal stromal tumor was suspected on endoscopic ultrasound (EUS) examination. It was confirmed histopathologically as metastatic ovarian adenocarcinoma after endoscopic submucosal dissection (ESD) with enucleation. Submucosal tumor of the stomach in patients with ovarian carcinoma should not be overlooked and ESD with enucleation may be a viable option when EUS with fine needle aspiration is not available.
Ovarian adenocarcinoma; Gastric metastasis; Submucosal tumor
The efficacy, safety and clinical outcomes of a combination of endoscopic submucosal dissection (ESD) with subsequent chemoradiation therapy (CRT) for superficial esophageal squamous cell carcinomas (superficial ESCC) remain unclear. We assessed the outcome of the combination of ESD plus CRT for superficial ESCC. Fourteen patients with superficial ESCC invading into the muscularis mucosa or submucosa were treated with ESD plus CRT from 2004 to 2010. En bloc resection of the lesion was successfully performed in all patients. The mean diameter of the lesions was 25 mm (range 10–55). The distribution of the depth of tumor invasion was to the muscularis mucosa in 8 patients, to the upper submucosal third (sm1) in 4 patients and to the middle submucosal third (sm2) in 2 patients. The laterally resected margins and vascular invasion were cancer-negative in all patients, but lymph node involvement was detected in 2 patients. The mean follow-up period after CRT was 45 months (range 19–70). No patients died of esophageal cancer. Recurrence or metastasis of the esophageal cancer was not observed in any of the patients. The combination of ESD plus CRT is effective for superficial ESCC.
esophageal cancer; endoscopic submucosal dissection; chemoradiation therapy
Although endoscopic submucosal dissection (ESD) gains acceptance as one of the standard treatments for esophageal and stomach neoplasms in Japan, it is still in the developing stage for colorectal neoplasms. In terms of indications, little likelihood of nodal metastasis and technical resectability are principally considered. Some of intramucosal neoplasms, carcinomas with minute submucosal invasion, and carcinoid tumors, which are technically unresectable by conventional endoscopic treatments, may become good candidates for ESD, considering substantial risks and obtained benefits. ESD as a staging measure to obtain histological information of the invasion depth and lymphovascular infiltration is acceptable because preoperative prediction is difficult in some cases. In terms of techniques, advantages of ESD in comparison with other endoscopic treatments are to be controllable in size and shape, and to be resectable even in large and fibrotic neoplasms. The disadvantages may be longer procedure time, heavier bleeding, and higher possibility of perforation. However, owing to refinement of the techniques, invention of devices, and the learning curve, acceptable technical safety has been achieved. Colorectal ESD is very promising and become one of the standard treatments for colorectal neoplasms in the near future.
Colorectal neoplasm; Early colorectal cancer; Endoscopic submucosal dissection; Endoscopic mucosal resection; Endoluminal surgery
Endoscopic submucosal dissection (ESD) has enabled en bloc resection of early stage gastrointestinal tumors with negligible risk of lymph node metastasis, regardless of tumor size, location, and shape. However, ESD is a relatively difficult technique compared with conventional endoscopic mucosal resection, requiring a longer procedure time and potentially causing more complications. For safe and reproducible procedure of ESD, the appropriate dissection of the ramified vascular network in the level of middle submucosal layer is required to reach the avascular stratum just above the muscle layer. The horizontal approach to maintain the appropriate depth for dissection beneath the vascular network enables treatment of difficult cases with large vessels and severe fibrosis. The most important aspect of ESD is the precise evaluation of curability. This approach can also secure the quality of the resected specimen with enough depth of the submucosal layer.
Endoscopic submucosal dissection; Gastro intestinal neoplasms; Quality control; Dissection level; Vessel network
AIM: To investigate the feasibility and safety of the treatment of an upper gastrointestinal (GI) submucosal tumor with endoscopic submucosal dissection (ESD).
METHODS: A total of 20 patients with esophageal and gastric submucosal tumors emerged from the muscular layer identified by endoscopic ultrasonography were collected from January 2009 to June 2010. Extramural or dumbbell-like lesions were excluded by an enhanced computerized tomography (CT) scan. All patients had intravenous anesthesia with propofol and then underwent the ESD procedure to resect these submucosal tumors. The incision was closed by clips as much as possible to decrease complications, such as bleeding or perforation, after resection of the tumor. All the specimens were collected and evaluated by hematoxylin, eosin and immunohistochemical staining, with antibodies against CD117, CD34, desmin, α-smooth muscle actin and vimentin to identify the characteristics of the tumors. Fletch’s criteria was used to evaluate the risk of gastrointestinal stromal tumors (GISTs). All patients underwent a follow-up endoscopy at 3, 6 and 12 mo and CT scan at 6 and 12 mo.
RESULTS: The study group consisted of 5 men and 15 women aged 45-73 years, with a mean age of 60.2 years. Three tumors were located in the esophagus, 9 in the gastric corpus, 4 in the gastric fundus, 3 lesions in the gastric antrum and 1 in the gastric angulus. Apart from the one case in the gastric angulus which was abandoned due to being deeply located in the serosa, 94.7% (18/19) achieved complete gross dissection by ESD with operation duration of 60.52 ± 30.32 min. The average maximum diameter of tumor was 14.8 ± 7.6 mm, with a range of 6 to 30 mm, and another lesion was ligated by an endoscopic ligator after most of the lesion was dissected. After pathological and immunohistochemical analysis, 12 tumors were identified as a GI stromal tumor and 6 were leiomyoma. Mitotic count of all 12 GIST lesions was fewer than 5 per 50 HPF and all lesions were at very low (9/12, 75.0%) or low risk (3/12, 25.0%) according to Fletch’s criteria. Procedure complications mainly included perforation and GI bleeding; perforation occurred in 1 patient and conservative treatment succeeded by a suturing clip and no post-operative GI bleeding occurred. All patients were followed up for 6.5 ± 1.8 mo (range, 3-12 mo) by endoscopy and abdominal CT. Local recurrence and metastasis did not occur in any patient.
CONCLUSION: ESD shows promise as a safe and feasible technique to resect esophageal and gastric submucosal tumors and the incidence of complications was very low. Clinical studies with more subjects and longer follow-up are needed to confirm its treatment value.
Endoscopic submucosal dissection; Stromal tumors; Leiomyoma; Upper gastrointestinal tract
Endoscopic submucosal dissection (ESD) enables direct submucosal dissection so that even large early-stage gastrointestinal tumors can be resected en bloc. ESD has recently been applied to the colorectum since it was originally developed for use in the stomach. However, colorectal ESD is technically more difficult with an increased risk of perforation compared with gastric ESD. In addition, this procedure is seldom performed in Western countries. Consequently, further technical advances and the availability of a suitable clinical training system are required for the extensive use of colorectal ESD. In this topic highlight, we review the most recent developments in colorectal ESD.
Endoscopic submucosal dissection; Colonoscopy; Colorectum; Complication; Perforation; Training
The diagnostic criteria for colonic intraepithelial tumors vary from country to country. While intramucosal adenocarcinoma is recognized in Japan, in Western countries adenocarcinoma is diagnosed only if the tumor invades to the submucosa and accesses the muscularis mucosae. However, endoscopic therapy, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), is used worldwide to treat adenoma and early colorectal cancer. Precise histopathological evaluation is important for the curativeness of these therapies as inappropriate endoscopic therapy causes local recurrence of the tumor that may develop into fatal metastasis. Therefore, colorectal ESD and EMR are not indicated for cancers with massive submucosal invasion. However, diagnosis of cancer with massive submucosal invasion by endoscopy is limited, even when magnifying endoscopy for pit pattern and narrow band imaging and flexible spectral imaging color of enhancement are performed. Therefore, occasional cancers with massive submucosal invasion will be treated by ESD and EMR. Precise histopathological evaluation of these lesions should be performed in order to determine the necessity of additional therapy, including surgical resection.
Endoscopic submucosal dissection; Endoscopic mucosal resection; Early colorectal cancer; Histopathology
AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer.
METHODS: Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD.
RESULTS: The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT-ESD group (57.6 ± 31.9 min vs 21.1 ± 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups.
CONCLUSION: IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. The long-term outcome needs to be evaluated in the future.
Remnant stomach; Distal gastrectomy; Gastric cancer; Endoscopic mucosal resection; Insulation-tipped diathermic knife
Endoscopic submucosal dissection (ESD) has allowed the achievement of histologically curative en bloc resection of gastrointestinal neoplasms regardless of size, permitting the resection of previously non-resectable tumors. The ESD technique for treatment of early gastric cancer has spread rapidly in Japan and a few other Asian countries due to its excellent eradication rate compared to endoscopic mucosal resection. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. We developed the grasping type scissor forceps (GSF) to resolve such ESD-related problems. Our animal and preliminary clinical studies showed that ESD using GSF is a safe (no intraoperative complication) and technically efficient (curative en bloc resection rate 92%) method for dissection of early gastrointestinal tumors. The use of GSF is a promising option for performing ESD on early stage GI tract tumors both safely and effectively.
Endoscopic submucosal dissection; Novel device; Grasping type scissor forceps; Early gastrointestinal tract neoplasms; Endoscopic therapy
The indications for endoscopic treatment have expanded in recent years, and relatively intestinal-type mucosal stomach carcinomas with a low potential for metastasis are now often resected en bloc by endoscopic submucosal dissection (ESD), even if they measure over 20 mm in size. However, ESD requires complex maneuvers, which entails a long operation time, and is often accompanied by complications such as bleeding and perforation. Many technical developments have been implemented to overcome these complications. The scope, cutting device, hemostasis device, and other supportive devices have been improved. However, even with these innovations, ESD remains a potentially complex procedure. One of the major difficulties is poor visualization of the submucosal layer resulting from the poor countertraction afforded during submucosal dissection. Recently, countertraction devices have been developed. In this paper, we introduce countertraction techniques and devices mainly for gastric cancer.
Countertraction; Endoscopic submucosal dissection; Gastric cancer
Endoscopic submucosal dissection (ESD) is a highly refined technique compared to conventional endoscopic mucosal resection. It enables complete resection of early gastric cancer (EGC) which has no possibility of lymph node metastasis. Indication for ESD of EGC generally entails early gastric cancer confined to the mucosa with well differentiated histology, though there are clinically suitable expanded criteria. As ESD requires specific skill and expertise, endoscopists need to be familiarized with basic methods and the use of special devices. The essence of the technique is to dissect the submucosal layer with direct vision and maintain the cutting plane above the underlying proper muscle layer. Although there are some differences in the detailed technical aspect, the cardinal method of ESD is now well established and standardized. Furthermore, research and development of new ESD devices that render more efficient, safe ESD are still in progress to improve the overall result of ESD on early gastric cancer.
Endoscopic submucosal dissection; Technique; Device; Early gastric cancer
As a minimally invasive technique, endoscopic resection may benefit patients diagnosed with early stage gastrointestinal neuroendocrine tumors (NETs). However, no studies have yet been published in which endoscopic submucosal dissection (ESD) has been applied for gastric NETs. For the first time a research group in China applied ESD to remove gastric NETs, and indicated that ESD should be considered for treatment of eligible gastric NETs because the technique shows a high histologically complete resection rate, provides accurate histopathological evaluation, has a low complication rate, and can be performed within a reasonable timeframe.
Gastric schwannomas are rare mesenchymal tumors of the gastrointestinal tract. They are usually misdiagnosed as other submucosal tumors preoperatively. Experience of the imaging features of gastric schwannomas is extremely limited. In this report, we summarize the features of a series of endoscopic ultrasound (EUS) images of gastric schwannomas in an effort to improve the diagnosis and differential diagnosis rate. We retrospectively reviewed the endosonographic features of four patients with gastric schwannomas and their computed tomography imaging results. Gastric schwannomas had heterogeneous hypoechogenicity or isoechogenicity, and a well-demarcated margin. The tumors originated from the fourth layer. Cystic changes and calcification were uncommon. Marginal hypoechoic haloes were observed in two patients. The results described here were different from those of previous studies. In the EUS evaluation, the internal echogenicity of gastric schwannomas was heterogeneous and low, but slightly higher than that of muscularis propria. These features might help us differentiate gastric schwannomas from other submucosal tumors. Further investigation is needed to differentiate these mesenchymal tumors.
Schwannomas; Endosonography; Stomach; Radiological examination; Imaging
Endoscopic treatment for duodenal bulb neuroendocrine tumor larger than 10 mm is still controversial. This report presents four cases successfully treated with endosonography (EUS)-assisted endoscopic mucosal resection (EMR) procedure for duodenal bulb neuroendocrine tumor larger than 10 mm in diameter.
The case series of four patients diagnosed with neuroendocrine tumor from 2003 to 2008 were reviewed. EUS demonstrated well-defined hypoechoic tumors confined to the submucosal hyperechoic layer and the underlying hypoechoic muscularis propria was intact in all four patients. EMR were planned and performed for the duodenal bulb neuroendocrine tumors larger than 10 mm.
En bloc resections with tumor free lateral and basal margins were accomplished using an endoscopic diathermic snare with forward-viewing instruments without any complications. Neither residual duodenal neuroendocrine tumors nor metastatic lesions were detected during the observation period ranging 19 to 78 months
Duodenal bulb neuroendocrine, larger than 10 mm in diameter, can be treated by endoscopic procedure, after confirming that the tumor confined to the submucosal layer in EUS examination, and no lymph node involvement by abdominal CT and US.
Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.
Endoscopic submucosal dissection; Esophageal cancer; Gastric cancer; Colorectal cancer; Laparoscopic surgery; Lymph node metastasis; Perforation; Gastrectomy; Complications
AIM: To investigate whether endoscopic submucosal dissection (ESD) can be safely performed at small clinics, such as the Shirakawa Clinic.
METHODS: One thousand forty-seven ESDs to treat gastrointestinal tumors were performed at the Shirakawa Clinic from April 2006 to March 2011. The efficacy, technical feasibility and associated complications of the procedures were assessed. The ESD procedures were performed by five endoscopists. Sedation was induced with propofol for esophagogastorduodenal ESD.
RESULTS: One thousand forty-seven ESDs were performed to treat 64 patients with esophageal cancer (E), 850 patients with gastric tumors (G: 764 patients with cancer, 82 patients with adenomas and four others), four patients with duodenal cancer (D) and 129 patients with colorectal tumors (C: 94 patients with cancer, 21 patients with adenomas and 14 others). The en bloc resection rate was 94.3% (E: 96.9%, G: 95.8%, D: 100%, C: 79.8%). The median operation time was 46 min (range: 4-360 min) and the mean size of the resected specimens was 18 mm (range: 2-150 mm). No mortal complications were observed in association with the ESD procedures. Perforation occurred in 12 cases (1.1%, E: 1 case, G: 9 cases, D: 1 case, C: 1 case) and postoperative bleeding occurred in 53 cases (5.1%, G: 51 cases, D: 1 case, C: 1 case); however, no case required either emergency surgery or blood transfusion. All of the perforations and postperative bleedings were resolved by endoscopic clipping or hemostasis. The other problematic complication observed was pneumonia, which was treated with conservative therapy.
CONCLUSION: ESD can be safely performed in a clinic with established therapeutic methods and medical services to address potential complications.
Endoscopic submucosal dissection; Complication; Perforation; Clinic
Endoscopic submucosal dissection (ESD) is reported to be an efficient treatment with a high rate of en bloc resection for large colorectal tumors in Japan and some other Western and Asian countries. ESD is considered less invasive than laparoscopic colectomy. However, ESD carries a higher risk of perforation than endoscopic mucosal resection (EMR). Various devices and training methods for colorectal ESD have been developed to solve the difficulties. In this review, we describe the complications of colorectal ESD and prevention of those complications. On the other hand, colorectal ESD is difficult for less-experienced endoscopists. The unique step-by-step ESD training system is performed in Japan. Additionally, appropriate training, including animal model training, for colorectal ESD should be acquired before working on clinical cases.