Esophageal cancer is one of the most unknown and deadliest cancers worldwide,mainly because of its extremely aggressive nature and poor survival rate.Esophageal cancer is the 6th leading cause of death from cancer and...Esophageal cancer is one of the most unknown and deadliest cancers worldwide,mainly because of its extremely aggressive nature and poor survival rate.Esophageal cancer is the 6th leading cause of death from cancer and the 8th most common cancer in the world.The 5-year survival is around 15%-25%.There are clear differences between the risk factors of both histological types that affect their incidence and distribution worldwide.There are areas of high incidence of squamous cell carcinoma(some areas in China) that meet the requirements for cost-effectiveness of endoscopy for early diagnosis in the general population of those areas.In Europe and United States the predominant histologic subtype is adenocarcinoma.The role of early diagnosis of adenocarcinoma in Barrett's esophagus remains controversial.The differences in the therapeutic management of early esophageal carcinoma(high-grade dysplasia,T1 a,T1 b,N0) between different parts of the world may be explained by the number of cancers diagnosed at an early stage.In areas where the incidence is high(China and Japan among others) early diagnoses is more frequent and has led to the development of endoscopic techniques for definitive treatment that achieve very effective results with a minimum number of complications and preserving the functionality of the esophagus.展开更多
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...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.展开更多
AIM:To assess risk factors for bleeding after gastric endoscopic submucosal dissection(ESD) and to develop preventive measures.METHODS:This retrospective study was performed in a tertiary referral center.A total of 32...AIM:To assess risk factors for bleeding after gastric endoscopic submucosal dissection(ESD) and to develop preventive measures.METHODS:This retrospective study was performed in a tertiary referral center.A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009.The main outcome was association between post-ESD bleeding and the following:age;sex;comorbidities;daily use of medicine potentially related to gastric injury/bleeding;location,size,and histological depth of lesions;ulceration;experience of operator coagulating the ulcer floor,and duration of operation.We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.RESULTS:Univariate analysis revealed significant risk factors:tumor location [odds ratio(OR),2.86;95% CI:1.21-6.79,P=0.024],coagulator experience(OR,4.29;95% CI:1.43-12.86,P=0.009),and medicine potentially related to gastric injury/bleeding(OR,2.80;95% CI:1.14-6.90,P=0.039).Multivariate logistic regression analysis confirmed significant,independent risk factors:tumor in lower third of stomach(OR,2.47;95% CI:1.02-5.96,P=0.044),beginner coagulator(OR,3.93;95% CI:1.29-11.9,P=0.016),and medicine(OR,2.76;95% CI:1.09-6.98,P=0.032).We classif ied cases of post-ESD bleeding into two groups(bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts(OR,16.00;95% CI:1.22-210.59,P=0.040).CONCLUSION:Beginner coagulators,tumor in the antrum,and medicines were significant risk factors for post-ESD bleeding.Bleeding at the ulcer margin frequently occurred with beginner operators.展开更多
AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Scho...AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Schol-ar and Cochrane library databases. Quality of each included study was assessed according to current Co-chrane guidelines. Primary endpoints were en bloc re-section rate and histologically complete resection rate. Secondary endpoints were length of procedure, post-treatment bleeding, post-procedural perforation and re-currence rate. Comparisons between the two treatment groups across all the included studies were performed by using Mantel-Haenszel test for fixed-effects mod-els(in case of low heterogeneity) or DerSimonian and Laird test for random-effects models(in case of high heterogeneity).RESULTS: Ten retrospective studies(8 full text and 2 abstracts) were included in the meta-analysis. Overall data on 4328 lesions, 1916 in the ESD and 2412 in the EMR group were pooled and analyzed. The mean operation time was longer for ESD than for EMR(stan-dardized mean difference 1.73, 95%CI: 0.52-2.95, P =0.005) and the "en bloc " and histological complete re-section rates were significantly higher in the ESD group [OR = 9.69(95%CI: 7.74-12.13), P < 0.001 and OR = 5.66,(95%CI: 2.92-10.96), P < 0.001, respectively]. As a consequence of its greater radicality, ESD provided lower recurrence rate [OR = 0.09,(95%CI: 0.05-0.17), P < 0.001]. Among complications, perforation rate was significantly higher after ESD [OR = 4.67,(95%CI, 2.77-7.87), P < 0.001] whereas the bleeding incidences did not differ between the two techniques [OR = 1.49(0.6-3.71), P = 0.39].CONCLUSION: In the endoscopic therapy of EGC, ESD showed a superior efficacy but higher complication rate with respect to EMR.展开更多
Gastric submucosal tumors(SMTs) are a rather frequent finding,occurring in about 0.36%of routine upper GIendoscopies.Endoscopic ultrasonography(EUS) has emerged as a reliable investigative procedure for evaluation of ...Gastric submucosal tumors(SMTs) are a rather frequent finding,occurring in about 0.36%of routine upper GIendoscopies.Endoscopic ultrasonography(EUS) has emerged as a reliable investigative procedure for evaluation of these lesions.Diagnostic EUS has the ability to differentiate intramural tumors from extraluminal compressions and can also show the layer of origin of gastric SMTs.Tumors can be further characterized by their layer of origin,echo pattern and margin.EUS-risk criteria of their malignant potential are presented,although the emergence of EUS-FNA has opened new indications for transmural tissue diagnosis and expanded the possibilities of EUS in SMTs of the stomach.Tissue diagnosis should address whether the SMT is a Gastrointestinal stromal tumour(GIST) or another tumor type and evaluate the malignant potential of a given GIST.However,there seems to be a lack of data on the optimal strategy in SMTs suspected to be GISTs with a negative EUS-FNA tissue diagnosis.The current management strategies,as well as open questions regarding their treatment are also presented.展开更多
The high incidence of gastric cancer has led to the initiation of cancer screening programs.As a result,the number of early gastric cancer cases has increased and consequentially,the cancer mortality rate has decrease...The high incidence of gastric cancer has led to the initiation of cancer screening programs.As a result,the number of early gastric cancer cases has increased and consequentially,the cancer mortality rate has decreased.Moreover,the development of minimally invasive endoscopic treatment has been introduced for these early lesions.Endoscopic submucosal dissection(ESD) is now recognized as one of the preferred treatment modalities for premalignant gastrointestinal epithelial lesions and early gastric cancer without lymph node metastasis.We review the results of ESD including experiences in Japan and Korea,as well as western countries.展开更多
This review is part two of three, which will present an update on the classification of gastrointestinal submucosal tumors. Part one treats of the diagnosis and part three of the therapeutic methods regarding gastroin...This review is part two of three, which will present an update on the classification of gastrointestinal submucosal tumors. Part one treats of the diagnosis and part three of the therapeutic methods regarding gastrointestinal submucosal tumors. In the past there has been some confusion as to the classification of gastrointestinal submucosal tumors. Changes in classifications have emerged due to recent advances in mainly immunohistochemistry and electron microscopy. The aim of this paper is to update the reader on the current classification. Literature searches were performed to find information related to classification of gastrointestinal submucosal tumors. Based on these searches the twelve most frequent submucosal tumor types were chosen for description of their classification. The factors that indicate whether tumors are benign or malignant are mainly size and number of mitotic counts. Gastrointestinal stromal tumors are defined mainly by their CD117 positivity. In the future, there should be no more confusion between gastrointestinal stromal tumors and other types of submucosal tumors.展开更多
AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane...AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients wer展开更多
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 th...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.展开更多
AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS:...AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS: We enrolled 23 patients who presented with gastrointestinal (GI) bleeding, fistulae and perforations and were treated with OTSCs (Ovesco Endoscopy GmbH, Tuebingen, Germany) between November 2011 and September 2012. Maximum lesion size was defined as lesion diameter. The number of OTSCs to be used per patient was not decided until the lesion was completely closed. We used a twin grasper (Ovesco Endoscopy GmbH, Tuebingen, Germany) as a grasping device for all the patients. A 9 mm OTSC was chosen for use in the esophagus and colon, and a 10 mm device was used for the stomach, duodenum and rectum. The overall success rate and complications were evaluated, with a particular emphasis on patients who had undergone ESD due to adenocarcinoma. In technical successful cases we included not only complete closing by using OTSCs, but also partial closing where complete closure with OTSCs is almost difficult. In overall clinical successful cases we included only complete closing by using only OTSCs perfectly. All the OTSCs were placed by 2 experienced endoscopists. The sites closed after ESD included not only the perforation site but also all defective ulcers sites.RESULTS: A total of 23 patients [mean age 77 years (range 64-98 years)] underwent OTSC placement during the study period. The indications for OTSC placement were GI bleeding (n = 9), perforation (n = 10), fistula (n = 4) and the prevention of post-ESD duodenal artificial ulcer perforation (n = 1). One patient had a perforation caused by a glycerin enema, after which a fistula formed. Lesion closure using the OTSC alone was successful in 19 out of 23 patients, and overall success rate was 82.6%. A large lesion size (greater than 20 mm) and a delayed diagnosis (more than 1 wk) were the major contributing factors for the overall unsuccessful clinical cases展开更多
Endoscopic polypectomy and endoscopic mucosal resection(EMR) are the established treatment standards for colorectal polyps. Current research aims at the reduction of both complication and recurrence rates as well as o...Endoscopic polypectomy and endoscopic mucosal resection(EMR) are the established treatment standards for colorectal polyps. Current research aims at the reduction of both complication and recurrence rates as well as on shortening procedure times. Cold snare resection is the emerging standard for the treatment of smaller(< 5 mm) polyps and is possibly also suitable for the removal of noncancerous polyps up to 9 mm. The method avoids thermal damage, has reduced procedure times and probably also a lower risk for delayed bleeding. On the other end of the treatment spectrum, endoscopic submucosal dissection(ESD)offers en bloc resection of larger flat or sessile lesions. The technique has obvious advantages in the treatment of high-grade dysplasia and early cancer. Due to its minimal recurrence rate, it may also be an alternative to fractionated EMR of larger flat or sessile lesions. However, ESD is technically demanding and burdened by longer procedure times and higher costs. It should therefore be restricted to lesions suspicious for high-grade dysplasia or early invasive cancer.The latest addition to endoscopic resection techniques is endoscopic fullthickness resection with specifically developed devices for flexible endoscopy.This method is very useful for the treatment of smaller difficult-to-resect lesions,e.g., recurrence with scar formation after previous endoscopic resections.展开更多
Endoscopic ultrasonography(EUS) is the most accurate procedure for detecting and diagnosing subepithelial tumors,due to its higher sensitivity and specificity than other imaging modalities.EUS can characterize lesions...Endoscopic ultrasonography(EUS) is the most accurate procedure for detecting and diagnosing subepithelial tumors,due to its higher sensitivity and specificity than other imaging modalities.EUS can characterize lesions by providing information on echogenic origin,size,borders,homogeneity,and the presence of echogenic or anechoic foci.Linear echoendoscopes,and recently also electronic radial echoendoscopes,can be used with color Doppler or power Doppler to assess the vascular signals from subepithelial masses,and thus permit the differentiation of vascular structures from cysts,as well as the assessment of the tumor blood supply.However,the diagnostic accuracy of EUS imaging alone has been shown to be low in subepithelial lesions with 3rd and 4th layers.It is also difficult to differentiate exactly between benign and malignant tumors and to gain an accurate picture of histology using EUS.On the other hands,EUS guided fine needle aspiration(EUS-FNA) can provide samples for cytologic or histologic analysis.Hypoechoic lesions of the 3rd and the 4th EUS layers,more than in 1 cm diameter are recommended,and histologic confirmation using endoscopic submucosal resection or EUSFNA should be obtained when possible.Therefore,EUSFNA plays an important role in the clinical management of subepithelial tumors.Furthermore improvements in endoscopic technology are expected to be more useful modalities in differential diagnosis and discrimination between benign and malignant subepithelial展开更多
Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring ex... Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.展开更多
Endoscopic submucosal dissection(ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus.An important advantage of ESD is its effectiv...Endoscopic submucosal dissection(ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus.An important advantage of ESD is its effectiveness in resecting lesions regardless of their size and severity of fibrosis.Based on excellent outcomes for esophageal neoplasms with a small likelihood of lymph node metastasis,the number of ESD candidates has increased.On the other hand,ESD still requires highly skilled endoscopists due to technical difficulties.To avoid unnecessary complications including perforation and postoperative stricture,the indications for ESD require careful consideration and a full understanding of this modality.This article,in the highlight topic series,provides detailed information on the indication,procedure,outcome,complications and their prevention in ESD of superficial esophageal neoplasms.展开更多
Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic fac...Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.展开更多
AIM: To investigate the effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in treating superficial esophageal cancer (SEC).
Endoscopic submucosal dissection (ESD) is efficient for en bloc resection of large colorectal tumors. However, it has several technical difficulties, because the wall of the colon is thin and due to the winding nature...Endoscopic submucosal dissection (ESD) is efficient for en bloc resection of large colorectal tumors. However, it has several technical difficulties, because the wall of the colon is thin and due to the winding nature of the colon. The main complications of ESD comprise postoperative perforation and hemorrhage, similar to endoscopic mucosal resection (EMR). In particular, the rate of perforation in ESD is higher than that in EMR. Perforation of the colon can cause fatal peritonitis. Endoscopic clipping is reported to be an efficient therapy for perforation. Most cases with perforation are treated conservatively without urgent surgical intervention. However, the rate of postoperative hemorrhage in ESD is similar to that in EMR. Endoscopic therapy including endoscopic clipping is performed and most of the cases are treated conservatively without blood transfusion. In blood examination, some degree of inflammation is detected after ESD. For the standardization of ESD, it is most important to decrease the rate of perforation. Adopting a safe strategy for ESD and a suitable choice of knife are both important waysof preventing perforation. Moreover, appropriate training and increasing experience can improve the endoscopic technique and can decrease the rate of perforation. In this review, we describe safe procedures in ESD to prevent complications, the complications of ESD and their management.展开更多
AIM： To report 13 patients with benign esophagea stenosis treated with the biodegradable stent. METHODS： We developed a Ultraflex-type stent by knitting poly-/-lactic acid rnonofilaments. RESULTS： Two cases were es...AIM： To report 13 patients with benign esophagea stenosis treated with the biodegradable stent. METHODS： We developed a Ultraflex-type stent by knitting poly-/-lactic acid rnonofilaments. RESULTS： Two cases were esophageal stenosis caused by drinking of caustic liquid, 4 cases were due to surgical resection of esophageal cancers, and 7 cases were patients with esophageal cancer who received the preventive placement of biodegradable stents for postendoscopic mucosal dissection （ESD） stenosis. The preventive placement was performed within 2 to 3 d after ESD. In 10 of the 13 cases, spontaneous migration of the stents occurred between 10 to 21 d after placement. In these cases, the migrated stents were excreted with the feces, and no obstructive complications were experienced. In 3 cases, the stents remained at the proper location on d 21 after placement. No symptoms of re-stenosis were observed within the follow-up period of 7 mo to 2 years. Further treatment with balloon dilatation or replacement of the biodegradable stent was not required. CONCLUSION： Biodegradable stents were useful for the treatment of benign esophageal stenosis, particularly for the prevention of post-ESD stenosis.展开更多
AIM To assess the effect of polyglycolic acid(PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection(ESD) esophageal stricture in early-stage esophagea...AIM To assess the effect of polyglycolic acid(PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection(ESD) esophageal stricture in early-stage esophageal cancer(EC) patients. METHODS Seventy EC patients undergoing ESD were enrolled in this randomized, controlled study. Patients were allocated randomly at a 1:1 ratio into two groups as follows:(1) PGA plus stent group(PGA sheet-coated stent placement was performed); and(2) Stent group(only stent placement was performed). This study was registered on http://www.chictr.org.cn(No. chictrinr-16008709). RESULTS The occurrence rate of esophageal stricture in the PGA plus stent group was 20.5%(n = 7), which was lower than that in the stent group(46.9%, n = 15)(P = 0.024). The mean value of esophageal stricture time was 59.6 ± 16.1 d and 70.7 ± 28.6 d in the PGA plus stent group and stent group(P = 0.174), respectively. Times of balloon dilatation in the PGA plus stent group were less than those in the stent group [4(2-5) vs 6(1-14), P = 0.007]. The length(P = 0.080) and diameter(P = 0.061) of esophageal strictures were numerically decreased in the PGA plus stent group, whereas no difference in location(P = 0.232) between the two groups was found. Multivariate logistic analysis suggested that PGA plus stent placement(P = 0.026) was an independent predictive factor for a lower risk of esophageal stricture, while location in the middle third(P = 0.034) and circumferential range = 1/1(P = 0.028) could independently predict a higher risk of esophageal stricture in EC patients after ESD. CONCLUSION PGA plus stent placement is more effective in preventing post-ESD esophageal stricture compared with stent placement alone in EC patients with earlystage disease.展开更多
This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments...This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.展开更多
文摘Esophageal cancer is one of the most unknown and deadliest cancers worldwide,mainly because of its extremely aggressive nature and poor survival rate.Esophageal cancer is the 6th leading cause of death from cancer and the 8th most common cancer in the world.The 5-year survival is around 15%-25%.There are clear differences between the risk factors of both histological types that affect their incidence and distribution worldwide.There are areas of high incidence of squamous cell carcinoma(some areas in China) that meet the requirements for cost-effectiveness of endoscopy for early diagnosis in the general population of those areas.In Europe and United States the predominant histologic subtype is adenocarcinoma.The role of early diagnosis of adenocarcinoma in Barrett's esophagus remains controversial.The differences in the therapeutic management of early esophageal carcinoma(high-grade dysplasia,T1 a,T1 b,N0) between different parts of the world may be explained by the number of cancers diagnosed at an early stage.In areas where the incidence is high(China and Japan among others) early diagnoses is more frequent and has led to the development of endoscopic techniques for definitive treatment that achieve very effective results with a minimum number of complications and preserving the functionality of the esophagus.
文摘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.
文摘AIM:To assess risk factors for bleeding after gastric endoscopic submucosal dissection(ESD) and to develop preventive measures.METHODS:This retrospective study was performed in a tertiary referral center.A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009.The main outcome was association between post-ESD bleeding and the following:age;sex;comorbidities;daily use of medicine potentially related to gastric injury/bleeding;location,size,and histological depth of lesions;ulceration;experience of operator coagulating the ulcer floor,and duration of operation.We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.RESULTS:Univariate analysis revealed significant risk factors:tumor location [odds ratio(OR),2.86;95% CI:1.21-6.79,P=0.024],coagulator experience(OR,4.29;95% CI:1.43-12.86,P=0.009),and medicine potentially related to gastric injury/bleeding(OR,2.80;95% CI:1.14-6.90,P=0.039).Multivariate logistic regression analysis confirmed significant,independent risk factors:tumor in lower third of stomach(OR,2.47;95% CI:1.02-5.96,P=0.044),beginner coagulator(OR,3.93;95% CI:1.29-11.9,P=0.016),and medicine(OR,2.76;95% CI:1.09-6.98,P=0.032).We classif ied cases of post-ESD bleeding into two groups(bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts(OR,16.00;95% CI:1.22-210.59,P=0.040).CONCLUSION:Beginner coagulators,tumor in the antrum,and medicines were significant risk factors for post-ESD bleeding.Bleeding at the ulcer margin frequently occurred with beginner operators.
文摘AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Schol-ar and Cochrane library databases. Quality of each included study was assessed according to current Co-chrane guidelines. Primary endpoints were en bloc re-section rate and histologically complete resection rate. Secondary endpoints were length of procedure, post-treatment bleeding, post-procedural perforation and re-currence rate. Comparisons between the two treatment groups across all the included studies were performed by using Mantel-Haenszel test for fixed-effects mod-els(in case of low heterogeneity) or DerSimonian and Laird test for random-effects models(in case of high heterogeneity).RESULTS: Ten retrospective studies(8 full text and 2 abstracts) were included in the meta-analysis. Overall data on 4328 lesions, 1916 in the ESD and 2412 in the EMR group were pooled and analyzed. The mean operation time was longer for ESD than for EMR(stan-dardized mean difference 1.73, 95%CI: 0.52-2.95, P =0.005) and the "en bloc " and histological complete re-section rates were significantly higher in the ESD group [OR = 9.69(95%CI: 7.74-12.13), P < 0.001 and OR = 5.66,(95%CI: 2.92-10.96), P < 0.001, respectively]. As a consequence of its greater radicality, ESD provided lower recurrence rate [OR = 0.09,(95%CI: 0.05-0.17), P < 0.001]. Among complications, perforation rate was significantly higher after ESD [OR = 4.67,(95%CI, 2.77-7.87), P < 0.001] whereas the bleeding incidences did not differ between the two techniques [OR = 1.49(0.6-3.71), P = 0.39].CONCLUSION: In the endoscopic therapy of EGC, ESD showed a superior efficacy but higher complication rate with respect to EMR.
文摘Gastric submucosal tumors(SMTs) are a rather frequent finding,occurring in about 0.36%of routine upper GIendoscopies.Endoscopic ultrasonography(EUS) has emerged as a reliable investigative procedure for evaluation of these lesions.Diagnostic EUS has the ability to differentiate intramural tumors from extraluminal compressions and can also show the layer of origin of gastric SMTs.Tumors can be further characterized by their layer of origin,echo pattern and margin.EUS-risk criteria of their malignant potential are presented,although the emergence of EUS-FNA has opened new indications for transmural tissue diagnosis and expanded the possibilities of EUS in SMTs of the stomach.Tissue diagnosis should address whether the SMT is a Gastrointestinal stromal tumour(GIST) or another tumor type and evaluate the malignant potential of a given GIST.However,there seems to be a lack of data on the optimal strategy in SMTs suspected to be GISTs with a negative EUS-FNA tissue diagnosis.The current management strategies,as well as open questions regarding their treatment are also presented.
文摘The high incidence of gastric cancer has led to the initiation of cancer screening programs.As a result,the number of early gastric cancer cases has increased and consequentially,the cancer mortality rate has decreased.Moreover,the development of minimally invasive endoscopic treatment has been introduced for these early lesions.Endoscopic submucosal dissection(ESD) is now recognized as one of the preferred treatment modalities for premalignant gastrointestinal epithelial lesions and early gastric cancer without lymph node metastasis.We review the results of ESD including experiences in Japan and Korea,as well as western countries.
文摘This review is part two of three, which will present an update on the classification of gastrointestinal submucosal tumors. Part one treats of the diagnosis and part three of the therapeutic methods regarding gastrointestinal submucosal tumors. In the past there has been some confusion as to the classification of gastrointestinal submucosal tumors. Changes in classifications have emerged due to recent advances in mainly immunohistochemistry and electron microscopy. The aim of this paper is to update the reader on the current classification. Literature searches were performed to find information related to classification of gastrointestinal submucosal tumors. Based on these searches the twelve most frequent submucosal tumor types were chosen for description of their classification. The factors that indicate whether tumors are benign or malignant are mainly size and number of mitotic counts. Gastrointestinal stromal tumors are defined mainly by their CD117 positivity. In the future, there should be no more confusion between gastrointestinal stromal tumors and other types of submucosal tumors.
文摘AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients wer
文摘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.
文摘AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS: We enrolled 23 patients who presented with gastrointestinal (GI) bleeding, fistulae and perforations and were treated with OTSCs (Ovesco Endoscopy GmbH, Tuebingen, Germany) between November 2011 and September 2012. Maximum lesion size was defined as lesion diameter. The number of OTSCs to be used per patient was not decided until the lesion was completely closed. We used a twin grasper (Ovesco Endoscopy GmbH, Tuebingen, Germany) as a grasping device for all the patients. A 9 mm OTSC was chosen for use in the esophagus and colon, and a 10 mm device was used for the stomach, duodenum and rectum. The overall success rate and complications were evaluated, with a particular emphasis on patients who had undergone ESD due to adenocarcinoma. In technical successful cases we included not only complete closing by using OTSCs, but also partial closing where complete closure with OTSCs is almost difficult. In overall clinical successful cases we included only complete closing by using only OTSCs perfectly. All the OTSCs were placed by 2 experienced endoscopists. The sites closed after ESD included not only the perforation site but also all defective ulcers sites.RESULTS: A total of 23 patients [mean age 77 years (range 64-98 years)] underwent OTSC placement during the study period. The indications for OTSC placement were GI bleeding (n = 9), perforation (n = 10), fistula (n = 4) and the prevention of post-ESD duodenal artificial ulcer perforation (n = 1). One patient had a perforation caused by a glycerin enema, after which a fistula formed. Lesion closure using the OTSC alone was successful in 19 out of 23 patients, and overall success rate was 82.6%. A large lesion size (greater than 20 mm) and a delayed diagnosis (more than 1 wk) were the major contributing factors for the overall unsuccessful clinical cases
文摘Endoscopic polypectomy and endoscopic mucosal resection(EMR) are the established treatment standards for colorectal polyps. Current research aims at the reduction of both complication and recurrence rates as well as on shortening procedure times. Cold snare resection is the emerging standard for the treatment of smaller(< 5 mm) polyps and is possibly also suitable for the removal of noncancerous polyps up to 9 mm. The method avoids thermal damage, has reduced procedure times and probably also a lower risk for delayed bleeding. On the other end of the treatment spectrum, endoscopic submucosal dissection(ESD)offers en bloc resection of larger flat or sessile lesions. The technique has obvious advantages in the treatment of high-grade dysplasia and early cancer. Due to its minimal recurrence rate, it may also be an alternative to fractionated EMR of larger flat or sessile lesions. However, ESD is technically demanding and burdened by longer procedure times and higher costs. It should therefore be restricted to lesions suspicious for high-grade dysplasia or early invasive cancer.The latest addition to endoscopic resection techniques is endoscopic fullthickness resection with specifically developed devices for flexible endoscopy.This method is very useful for the treatment of smaller difficult-to-resect lesions,e.g., recurrence with scar formation after previous endoscopic resections.
基金Supported by The Japan Society for Promotion of Science,Research and Development Committee Program of The Japan Society of Ultrasonics in Medicine,Japan Research Foundation for Clinical Pharmacology,and Japanese Foundation for Research and Promotion of Endoscopy
文摘Endoscopic ultrasonography(EUS) is the most accurate procedure for detecting and diagnosing subepithelial tumors,due to its higher sensitivity and specificity than other imaging modalities.EUS can characterize lesions by providing information on echogenic origin,size,borders,homogeneity,and the presence of echogenic or anechoic foci.Linear echoendoscopes,and recently also electronic radial echoendoscopes,can be used with color Doppler or power Doppler to assess the vascular signals from subepithelial masses,and thus permit the differentiation of vascular structures from cysts,as well as the assessment of the tumor blood supply.However,the diagnostic accuracy of EUS imaging alone has been shown to be low in subepithelial lesions with 3rd and 4th layers.It is also difficult to differentiate exactly between benign and malignant tumors and to gain an accurate picture of histology using EUS.On the other hands,EUS guided fine needle aspiration(EUS-FNA) can provide samples for cytologic or histologic analysis.Hypoechoic lesions of the 3rd and the 4th EUS layers,more than in 1 cm diameter are recommended,and histologic confirmation using endoscopic submucosal resection or EUSFNA should be obtained when possible.Therefore,EUSFNA plays an important role in the clinical management of subepithelial tumors.Furthermore improvements in endoscopic technology are expected to be more useful modalities in differential diagnosis and discrimination between benign and malignant subepithelial
文摘 Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.
文摘Endoscopic submucosal dissection(ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus.An important advantage of ESD is its effectiveness in resecting lesions regardless of their size and severity of fibrosis.Based on excellent outcomes for esophageal neoplasms with a small likelihood of lymph node metastasis,the number of ESD candidates has increased.On the other hand,ESD still requires highly skilled endoscopists due to technical difficulties.To avoid unnecessary complications including perforation and postoperative stricture,the indications for ESD require careful consideration and a full understanding of this modality.This article,in the highlight topic series,provides detailed information on the indication,procedure,outcome,complications and their prevention in ESD of superficial esophageal neoplasms.
文摘Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.
文摘AIM: To investigate the effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in treating superficial esophageal cancer (SEC).
文摘Endoscopic submucosal dissection (ESD) is efficient for en bloc resection of large colorectal tumors. However, it has several technical difficulties, because the wall of the colon is thin and due to the winding nature of the colon. The main complications of ESD comprise postoperative perforation and hemorrhage, similar to endoscopic mucosal resection (EMR). In particular, the rate of perforation in ESD is higher than that in EMR. Perforation of the colon can cause fatal peritonitis. Endoscopic clipping is reported to be an efficient therapy for perforation. Most cases with perforation are treated conservatively without urgent surgical intervention. However, the rate of postoperative hemorrhage in ESD is similar to that in EMR. Endoscopic therapy including endoscopic clipping is performed and most of the cases are treated conservatively without blood transfusion. In blood examination, some degree of inflammation is detected after ESD. For the standardization of ESD, it is most important to decrease the rate of perforation. Adopting a safe strategy for ESD and a suitable choice of knife are both important waysof preventing perforation. Moreover, appropriate training and increasing experience can improve the endoscopic technique and can decrease the rate of perforation. In this review, we describe safe procedures in ESD to prevent complications, the complications of ESD and their management.
文摘AIM： To report 13 patients with benign esophagea stenosis treated with the biodegradable stent. METHODS： We developed a Ultraflex-type stent by knitting poly-/-lactic acid rnonofilaments. RESULTS： Two cases were esophageal stenosis caused by drinking of caustic liquid, 4 cases were due to surgical resection of esophageal cancers, and 7 cases were patients with esophageal cancer who received the preventive placement of biodegradable stents for postendoscopic mucosal dissection （ESD） stenosis. The preventive placement was performed within 2 to 3 d after ESD. In 10 of the 13 cases, spontaneous migration of the stents occurred between 10 to 21 d after placement. In these cases, the migrated stents were excreted with the feces, and no obstructive complications were experienced. In 3 cases, the stents remained at the proper location on d 21 after placement. No symptoms of re-stenosis were observed within the follow-up period of 7 mo to 2 years. Further treatment with balloon dilatation or replacement of the biodegradable stent was not required. CONCLUSION： Biodegradable stents were useful for the treatment of benign esophageal stenosis, particularly for the prevention of post-ESD stenosis.
文摘AIM To assess the effect of polyglycolic acid(PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection(ESD) esophageal stricture in early-stage esophageal cancer(EC) patients. METHODS Seventy EC patients undergoing ESD were enrolled in this randomized, controlled study. Patients were allocated randomly at a 1:1 ratio into two groups as follows:(1) PGA plus stent group(PGA sheet-coated stent placement was performed); and(2) Stent group(only stent placement was performed). This study was registered on http://www.chictr.org.cn(No. chictrinr-16008709). RESULTS The occurrence rate of esophageal stricture in the PGA plus stent group was 20.5%(n = 7), which was lower than that in the stent group(46.9%, n = 15)(P = 0.024). The mean value of esophageal stricture time was 59.6 ± 16.1 d and 70.7 ± 28.6 d in the PGA plus stent group and stent group(P = 0.174), respectively. Times of balloon dilatation in the PGA plus stent group were less than those in the stent group [4(2-5) vs 6(1-14), P = 0.007]. The length(P = 0.080) and diameter(P = 0.061) of esophageal strictures were numerically decreased in the PGA plus stent group, whereas no difference in location(P = 0.232) between the two groups was found. Multivariate logistic analysis suggested that PGA plus stent placement(P = 0.026) was an independent predictive factor for a lower risk of esophageal stricture, while location in the middle third(P = 0.034) and circumferential range = 1/1(P = 0.028) could independently predict a higher risk of esophageal stricture in EC patients after ESD. CONCLUSION PGA plus stent placement is more effective in preventing post-ESD esophageal stricture compared with stent placement alone in EC patients with earlystage disease.
文摘This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.
