Haruhisa Suzuki

Complications of Gastric Endoscopic Submucosal Dissection

Endoscopic resection is now a widely accepted treatment for early gastric cancer, having a negligible risk of lymph‐node metastasis. Endoscopic submucosal dissection (ESD) is a relatively new endoscopic resection method developed in the mid‐1990s that facilitates en‐bloc resection even in patients with large or ulcerative lesions difficult to resect using conventional endoscopic mucosal resection (EMR). However, compared to EMR, ESD requires a longer procedure time and a higher level of technical expertise, in addition to having a slightly greater risk of complications. Endoscopists must be aware of not only the risk factors for, and incidence of, complications, but also how to effectively treat such complications. Perforation and bleeding are the major complications associated with gastric ESD. The perforation and delayed bleeding rates have been reported to range from 1.2% to 5.2% and 0% to 15.6%, respectively, and can usually be managed with appropriate endoscopic treatment. Immediate bleeding during gastric ESD is quite common and controlling such bleeding, which is primarily achieved by carrying out electrocautery, plays a critical role in the successful completion of ESD.

Short- and long-term outcomes of endoscopic submucosal dissection for undifferentiated early gastric cancer.

BACKGROUND AND STUDY AIMS Intramucosal undifferentiated early gastric cancer (EGC) up to 2 cm in size without ulceration has been treated by endoscopic submucosal dissection (ESD) because the incidence of lymph node metastasis is negligible. The aim of this retrospective study was to clarify the short-term and long-term outcomes of ESD carried out to treat undifferentiated EGC. PATIENTS AND METHODS Between January 1999 and September 2011, 113 patients with poorly differentiated adenocarcinoma or signet ring cell carcinoma on preoperative biopsy underwent ESD. In 16 patients differentiated EGC had been diagnosed after the ESD and these patients were excluded from the study. Short-term outcomes were evaluated in the remaining 97 patients with undifferentiated EGC, and long-term outcomes analyzed in the 79 patients with undifferentiated EGC who had undergone ESD between 1999 and 2008. RESULTS En bloc and R0 resection were achieved in 99.0 % and 90.7 % of patients, respectively. Median procedure time was 45 minutes. Postoperative bleeding, perforation during the procedure, and delayed perforation were noted in 4.1 %, 3.1 %, and 1.0 % respectively. Curative resection was achieved in 63.9 %. Additional surgery was performed in 21 of 35 patients in whom resection was noncurative: one (4.8 %) had local residual tumor and two (9.5 %) had lymph node metastases. Of the 46 /79 patients in the long-term outcome group who had curative resection, none had local recurrence or lymph node or distant metastasis during a median follow-up of 76.4 months. The 5-year overall mortality rate after curative resection was 7.0 %, and no patient died of gastric cancer. CONCLUSIONS ESD for undifferentiated EGC can achieve curative resection with an excellent 5-year mortality rate.

ROLE OF ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION (EUS-FNA) FOR DIAGNOSIS OF SOLID PANCREATIC MASSES

Since it was developed in 1992, endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) has been widely used and has been adapted for gastrointestinal and perigastrointestinal lesions. A medical literature review to evaluate the role of EUS‐FNA for diagnosis of solid pancreatic masses showed a 78–95% sensitivity, 75–100% specificity, 98–100% positive predictive value, 46–80% negative predictive value and a 78–95% accuracy. The reported complication rates of EUS‐FNA for pancreatic solid masses were 0–2%, although the criteria for complications varied among the studies. Because of its high diagnostic yield and low complication rate, EUS‐FNA is cost‐effective and widely applicable for the diagnosis of solid pancreatic masses, and is the best initial and the preferred secondary method compared with other biopsy techniques, such as endoscopic retrograde cholangiopancreatography‐guided biopsy, computed tomography/ultrasound‐FNA and surgery. Although EUS‐FNA is ‘a nearly perfected procedure,’ controversy remains, such as the most suitable diameter of the needle, the appropriate number of needle passes and the necessity of on‐site cytopathological evaluation. Recently investigators reported that using molecular analysis of EUS‐FNA samples can achieve a higher diagnostic efficacy. Further research is encouraged to optimize the EUS‐FNA procedure to reach its maximum diagnostic yield for solid pancreatic masses.

LEARNING CURVE FOR ENDOSCOPIC SUBMUCOSAL DISSECTION OF EARLY GASTRIC CANCER BASED ON TRAINEE EXPERIENCE

Background and Aim:  There have been few previous reports on endoscopic submucosal dissection (ESD) learning curve for early gastric cancer (EGC) so we retrospectively assessed this subject based on experience of our trainees.

Detection of early gastric cancer: misunderstanding the role of mass screening.

BackgroundThe proportion of early gastric cancer (EGC) increased from 15% during the 1960s to 50% recently, leading to a remarkable improvement of the 5-year survival rate of gastric cancer patients from 40% to 70%. This has been attributed to mass screening together with extended lymphadenectomy. However, more and more patients with EGC are diagnosed outside of mass screening. The aim of this study was to determine whether patients are symptomatic at the time of early detection and the method of tumor detection.MethodsFrom 2001 to 2003, a total of 1226 patients (male/female 2.2 : 1.0, age 26–95 years) with EGC were treated at the National Cancer Center Hospital, Tokyo. We reviewed their medical records.ResultsOf these 1226 patients, 512 (41.8%) were symptomatic, and 714 (58.2%) reported no symptoms. Among the symptomatic patients, 468 (91.4%) were examined at outpatient clinics, 39 (7.6%) by private health assessment clinics, and 5 (1.0%) by mass screening. In total, 91.6% of the symptomatic patients directly underwent esophagogastro-duodenoscopy (EGD). Of the asymptomatic patients, 320 (44.8%) were examined at outpatient clinics, 306 (42.9%) by private health assessment clinics, and 88 (12.3%) by mass screening. EGD was the initial assessment in 67.8% and radiography in 32.2% of asymptomatic patients.ConclusionMost patients with EGC were detected outside of mass screening. This suggests that the Japanese public and physicians are well aware of the risk of gastric cancer and the importance of early detection. The effect of mass screening is misunderstood.

Clinical outcome of endoscopic resection for nonampullary duodenal tumors

BACKGROUND AND STUDY AIMS Compared with any other location in the gastrointestinal tract, the duodenum presents the most challenging site for endoscopic resection. The aim of this study was to analyze the clinical outcomes of duodenal endoscopic resection and to assess the feasibility of the technique as a therapeutic procedure. PATIENTS AND METHODS A total of 113 consecutive patients with 121 nonampullary duodenal tumors underwent endoscopic resection by endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), or polypectomy between January 2000 and September 2013. Long-term outcomes were investigated in patients with more than 1 year follow-up. RESULTS The median tumor size was 12 mm (range 3 - 50 mm). Lesions consisted of 63 adenocarcinomas/high-grade intraepithelial neoplasias (53 %) and 57 adenomas/low-grade intraepithelial neoplasias (48 %). Endoscopic resection included 106 EMRs (87 %), 8 ESDs (7 %), and 7 polypectomies (6 %). En bloc resection was achieved in 77 lesions (64 %), and 43 lesions (35 %) underwent piecemeal resection; one procedure was discontinued due to perforation. There were 14 cases of delayed bleeding after EMR (12 %), 1 perforation (1 %) during ESD, and 1 delayed perforation (1 %) after ESD, which required emergency surgery. Of the 76 patients who were followed for more than 1 year, none of the patients died from a primary duodenal neoplasm, and there were no local recurrences during the 51-month median follow-up period (range 12 - 163 months). CONCLUSIONS Duodenal endoscopic resection was feasible as a therapeutic procedure, but it should only be performed by highly skilled endoscopists because of its technical difficulty. Piecemeal resection by EMR is acceptable for small lesions, based on these excellent long-term outcomes.

Treatment strategy for laterally spreading tumors in Japan: Before and after the introduction of endoscopic submucosal dissection

Background and Aims:  Laterally spreading tumors (LST) in the colorectum are considered good candidates for endoscopic resection (ER). Because LST‐non‐granular (NG) tumors show multifocal invasion into the submucosal layer, en bloc resection is necessary for adequate histopathological evaluation. Therefore, surgical resection has been recommended when a lesion is suspected to be an invasive cancer and too large to resect en bloc. The aim of the present study was to evaluate whether the introduction of colorectal ESD, which was developed for en bloc resection of early gastric cancers, could improve the en bloc resection rate of large LST‐NG‐type tumors and reduce the surgical resection rate.

Scheduled second-look endoscopy is not recommended after endoscopic submucosal dissection for gastric neoplasms (the SAFE trial): a multicentre prospective randomised controlled non-inferiority trial

Objective To clarify the effectiveness of second-look endoscopy (SLE) at preventing bleeding after gastric endoscopic submucosal dissection (ESD). Design A multicentre prospective randomised controlled non-inferiority trial was conducted at five referral institutions across Japan. Patients with a solitary gastric neoplasm were enrolled. Exclusion criteria were previous oesophagogastric surgery or radiation therapy; perforation and the administration of antithrombotics, steroids or non-steroidal anti-inflammatory drugs. Patients were assigned to the SLE group or the non-SLE group by a computer-generated random sequence after ESD and were treated perioperatively with a proton pump inhibitor. SLE was performed one day after ESD. The primary endpoint was post-ESD bleeding, defined as an endoscopically proven haemorrhage. The trial had the power to detect a non-inferiority criterion of 7% between the groups. Results From February 2012 to February 2013, 130 and 132 patients were assigned to the SLE and the non-SLE groups, respectively. All patients were included in the intention-to-treat analysis of the primary endpoint. Post-ESD bleeding occurred in seven patients with (5.4%) SLE and five patients with (3.8%) non-SLE (risk difference −1.6% (95% CI −6.7 to 3.5); pnon-inferiority<0.001), meeting the non-inferiority criterion. All 12 patients with post-ESD bleeding and one patient with a delayed perforation were successfully managed with conservative treatment. Conclusions SLE after gastric ESD is not routinely recommended because it does not contribute to the prevention of post-ESD bleeding for patients with an average bleeding risk. Trial registration number UMIN-CTR000007170.

Endoscopic submucosal dissection of recurrent or residual superficial esophageal cancer after chemoradiotherapy

BACKGROUND Treatment of local recurrent or residual superficial esophageal squamous-cell carcinoma (SCC) with conventional EMR often results in a piecemeal resection that requires further intervention. OBJECTIVE The aim of this study was to evaluate the efficacy of endoscopic submucosal dissection (ESD). DESIGN A case series. PATIENTS Between January 2006 and September 2006, 4 local recurrent or residual superficial esophageal SCCs were treated by ESD. INTERVENTIONS ESD procedures were performed by using a bipolar needle knife and an insulation-tipped knife. After injection of glycerol into the submucosal (sm) layer, a circumferential incision was made, and an sm dissection was performed. All lesions were determined to be intramucosal or sm superficial, without lymph-node metastasis by EUS before treatment. MAIN OUTCOME MEASUREMENTS Tumor size, en bloc resection rate, tumor-free lateral margin rates, and complications were recorded. RESULTS All 4 ESD cases were successfully resected en bloc, and the tumor-free lateral margin rate was 75% (3/4) by histopathology examination. The mean tumor size of the resected specimens was 35 mm (range, 15-50 mm). There were no complications. LIMITATIONS The number of ESDs in our series was limited, and there are no long-term follow-up data. CONCLUSIONS ESD for recurrent or residual superficial esophageal tumors after chemoradiotherapy achieves the goal of an en bloc resection, with a low rate of incomplete treatment without any greater risk than the EMR technique.

Feasibility of endoscopic mucosal resection for superficial pharyngeal cancer: a minimally invasive treatment

BACKGROUND AND STUDY AIMS New diagnostic techniques have recently been developed so detection of superficial pharyngeal cancer is dramatically increasing and endoscopic mucosal resection (EMR) can now be performed on an experimental basis. The aim of this study was to clarify the effectiveness of EMR for superficial pharyngeal cancer. PATIENTS AND METHODS Between 2004 and 2007, 31 patients with 37 pharyngeal lesions underwent EMR at our hospital. EMR using a cap-fitted endoscope (EMR-C) was used on 34 lesions and strip biopsies on the remaining three. We retrospectively assessed the effectiveness of those procedures in treating superficial pharyngeal cancer. RESULTS Median procedure time was 45 minutes (range 20 - 180 minutes) and median hospital stay was 7 days (range 4 - 12 days). Regarding complications, one patient experienced laryngeal edema, one suffered aspiration pneumonia, and two sustained dermatitis around the mouth caused by Lugol staining. Histologically, 18 lesions were confirmed as carcinoma in situ and the other 19 lesions demonstrated microinvasion of the subepithelial tissue with lymphatic invasion in one case. During the median follow-up period of 40 months (range 21 - 62 months), two patients received radiotherapy and two patients underwent an additional EMR because of recurrent tumors. Five other patients developed metachronous superficial pharyngeal cancers, but all those lesions were resected primarily by EMR while two of the studys 31 patients died from esophageal cancer. None of the remaining 20 patients experienced any recurrent or metachronous tumors during their follow-up periods. CONCLUSIONS Our results indicated that EMR was a safe, effective, and minimally invasive treatment for superficial pharyngeal cancer.