Mariko Man-i

Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum

BACKGROUND AND STUDY AIMS Laterally spreading tumors - non granular type (LST-NG) are more often considered candidates for endoscopic submucosal dissection (ESD) than laterally spreading tumors - granular type (LST-G), because of their higher potential for submucosal invasion. However, ESD for LST-NG can be technically difficult. The aim of our study was to compare our ESD results for LST-NG and for LST-G. PATIENTS AND METHODS Ninety-nine LST-NG and 169 LST-G measuring 20 mm in size or more were removed by ESD. We retrospectively evaluated the clinicopathological features of the tumors and treatment results (en bloc resection rate, procedure time and speed, rate of use of ancillary devices, and complication and recurrence rates). RESULTS Histopathology revealed that there were more submucosally invasive lesions in the LST-NG than in the LST-G group (28 % vs. 9 %; P < 0.0001). The en bloc resection rate, en bloc R0 resection rate, and en bloc curative resection rate of LST-NG were similar to those of LST-G (LST-NG: 99 %, 98 %, and 88 %; LST-G: 99 %, 98 %, and 91 %). In LST-NG, the median procedure time tended to be longer (LST-NG: 69 min; LST-G: 60 min) and the median procedure speed was slower (LST-NG: 0.15 cm (2)/min; LST-G: 0.25 cm (2)/min; P < 0.0001). Use of ancillary devices was higher for LST-NG (38 % vs. 15 % for LST-G; P < 0.0001), as was the perforation rate (5.1 % vs. 0.6 % for LST-G; P = 0.027). No recurrence was seen in either group. CONCLUSIONS ESD was an effective treatment method for both LST-NG and LST-G. However, the degree of technical difficulty appears higher for LST-NG than for LST-G lesions, as shown by the lower dissection speed and higher perforation rate. ESD for LST-NG should probably be performed by those with significant experience of colorectal ESD.

The performance of a novel ball-tipped Flush knife for endoscopic submucosal dissection: a case-control study

Aliment Pharmacol Ther 2010; 32: 908–915

THE NEW RESOURCES OF TREATMENT FOR EARLY STAGE COLORECTAL TUMORS: EMR WITH SMALL INCISION AND SIMPLIFIED ENDOSCOPIC SUBMUCOSAL DISSECTION

Introduction:  Early stage colorectal tumors can be removed by endoscopic mucosal resection (EMR) but larger tumors (≧20 mm) may require piecemeal resection. The development of endoscopic submucosal dissection (ESD) has enabled en‐bloc resection of lesions regardless of size and shape. However ESD of colorectal tumor is technically difficult. As the resources, we perform EMR with small incision (EMR with SI) for more reliable EMR, and also ESD with snaring (simplified ESD) for easier and safer ESD.

Endoscopic Submucosal Dissection (ESD) Versus Simplified/Hybrid ESD

The development of endoscopic submucosal dissection (ESD) has enabled en bloc resection of lesions regardless of size and shape. However, ESD of colorectal tumors is technically difficult. Early stage colorectal tumors can be removed by endoscopic mucosal resection (EMR) but larger tumors may require piecemeal resection. Therefore, ESD with snaring has been proposed for more reliable EMR and easier ESD. This is a good option to fill the gap between EMR and ESD, and a good step to the introduction of full ESD.

Principles of Quality Controlled Endoscopic Submucosal Dissection with Appropriate Dissection Level and High Quality Resected Specimen

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.

Robot-assisted surgery for gastric cancer: experience at our institute.

Objective: The robot-assisted surgical system was developed for minimally invasive surgery and is thought to have the potential to overcome the shortcomings of laparoscopic surgery. We introduced this system for the treatment of gastric cancer in 2008. Here we report our initial experiences of robot-assisted surgery using the da Vinci system. Methods: A retrospective review of robot-assisted gastrectomy for gastric cancer patients was performed in our institute. The clinicopathological features and surgical outcomes were analyzed. Whereas the procedures of the gastrectomy were similar to those of the usual laparoscopic surgery, several aspects such as the port placement and the role of the assistant were modified from those for conventional laparoscopic surgery. Results: From January 2008 to December 2010, 61 patients with gastric cancer underwent robot-assisted surgery. Gastrectomy was distal in 46 patients, total in 14, proximal in 1 and no operation was converted to the open procedure. D2 lymph node dissection was performed on 28 patients in the distal gastrectomy group and on 11 in the total gastrectomy group. Complications occurred in 2 cases (4%): these consisted of ruptured sutures and hemorrhage from the anastomotic site. Conclusions: This study demonstrated that robot-assisted gastrectomy using the da Vinci system can be applied safely and effectively for patients with gastric cancer.

La dissection sous-muqueuse endoscopique au moyen d’un bistouri à aiguille courte avec jet d’eau (Flush-Knife) dans le traitement des néoplasies épithéliales du tractus digestif

RésuméNous avons mis au point des bistouris à aiguille courte capables d’émettre un jet d’eau à l’extrémité de la gaine (Flush-knife) afin de réaliser des dissections sous-muqueuses endoscopiques (DSE) avec plus de facilité, de sécurité et d’efficacité. Le raccourcissement de l’extrémité du bistouri à aiguille permet un marquage très fin, une incision de la muqueuse et une dissection de la sous-muqueuse faciles et sûres. L’émission d’un jet d’eau à partir de l’extrémité du cathéter permet le lavage du champ visuel, la mise en évidence des sites hémorragiques et en outre, l’injection locale sous-muqueuse sans remplacement des instruments opératoires et ceci grâce au bistouri, permettant ainsi un traitement très efficace. Le flush-knife peut être considéré comme un des instruments opératoires utiles dans le cadre de la DSE.SummaryWe invented short needle knives that can emit a jet of water from the tip of a sheath (Flush knife) in order to perform endoscopic submucosal dissection (ESD) more easily, safely, and efficiently. Shortening of the projecting part of the tip of a needle knife enabled small sharp marking, easy and safe incision of mucosa, and submucosal dissection. Emitting a jet of water from the tip of a sheath enables lavage of the viewing field, identification of the bleeding points, and submucosal local injection without replacement of operative instruments and with a knife itself, which led to very efficient treatment. Flush knife can be considered to be one of the useful operative instruments for ESD.

Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection

Background and study aims: During colorectal endoscopic submucosal dissection (ESD), the feature of a muscle layer being pulled toward a neoplastic tumor is sometimes detected. We call this feature the muscle-retracting sign (MR sign). The aim of this study was to evaluate whether the MR sign is associated with particular types of neoplastic lesions and whether it has any clinical significance for ESD sessions. Patients and methods: A total of 329 patients underwent ESD for 357 colorectal neoplasms. The frequency of positivity for the MR sign was evaluated in different morphologic and histopathologic types of neoplasm. The success rate of complete resection and the incidence of complications were also evaluated according to whether lesions were positive or negative for the MR sign. Results: The rates of positivity for the MR sign in the various lesion types were as follows: laterally spreading tumor – granular nodular mixed type (LST-G-M), 9.6 %; laterally spreading tumor – granular homogeneous type (LST-G-H) and laterally spreading tumor – nongranular type (LST-NG), 0 %; sessile type, 41.2 %. The resection rate was 100 % (329 /329) in lesions negative for the MR sign; however, it was 64.3 % (18 /28) in lesions positive for the MR sign, which was significantly lower (P < 0.001). Conclusions: The MR sign was present only in some protruding lesions, and more importantly, it was associated with a high risk of incomplete tumor removal by ESD. Our data indicate that lesions positive for the MR sign lesions should be dissected with great caution; alternatively, based on the features of the individual case, a switch to surgery should be considered for the benefit of the patient.

Gastroenterological surgery: esophagus.

1-1 Which stages of thoracic esophageal cancer are indicated for thoracoscopic surgery? In many facilities, thoracoscopic surgery is indicated for cStages I, II, and III, except cT4, according to the TNM Classification of Malignant Tumours, seventh edition, or cStages I–IVa, except cT4, according to the Japanese Classification of Esophageal Cancer, 10th edition, edited by the Japan Esophageal Society.