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Endoscopic management of early gastric cancer: endoscopic mucosal resection or endoscopic submucosal dissection: data from a Japanese high-volume center and literature review.

Uedo N, Takeuchi Y, Ishihara R - Ann Gastroenterol (2012)

Bottom Line: Moreover, the specimens obtained by ESD facilitate precise histological assessment of curability compared with the piecemeal specimens obtained by EMR.Accordingly, ESD has been established as a standard treatment for management of EGC in Japan.The long-term outcome of endoscopic management of EGC is based on: a) the accuracy of endoscopic diagnosis which defines the optimal treatment; b) endoscopist's expertise on methods for tumor removal (currently techniques of ESD); c) precise histological assessment of the resected specimen for curability; and d) surveillance endoscopy for early detection of metachronous multiple cancer.

View Article: PubMed Central - PubMed

Affiliation: Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan Endoscopic Learning and Training Center, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

ABSTRACT
As detection of early gastric cancer (EGC) has improved, endoscopic mucosal resection (EMR) has been adopted as a treatment option for small intramucosal carcinoma. Endoscopic submucosal dissection (ESD) has enabled high en bloc resection rate for small and large lesions, as well as those with scarring. Moreover, the specimens obtained by ESD facilitate precise histological assessment of curability compared with the piecemeal specimens obtained by EMR. Accordingly, ESD has been established as a standard treatment for management of EGC in Japan. The long-term outcome of endoscopic management of EGC is based on: a) the accuracy of endoscopic diagnosis which defines the optimal treatment; b) endoscopist's expertise on methods for tumor removal (currently techniques of ESD); c) precise histological assessment of the resected specimen for curability; and d) surveillance endoscopy for early detection of metachronous multiple cancer. Efforts to establish a standardized protocol for practice and training can accelerate dissemination of gastric ESD in regions where gastric cancer is highly prevalent, and may help endoscopists worldwide to adopt this technique for other organs in the digestive tract.

No MeSH data available.


Related in: MedlinePlus

Representative devices used for gastric endoscopic submucosal dissection. (A) Insulation-tipped diathermic knife-2; (B) ball-tipped flush knife; (C) hook knife; (D) hemostatic forceps (Coagrasper)
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Figure 3: Representative devices used for gastric endoscopic submucosal dissection. (A) Insulation-tipped diathermic knife-2; (B) ball-tipped flush knife; (C) hook knife; (D) hemostatic forceps (Coagrasper)

Mentions: The original form of ESD was developed in the mid-1980s by Hirao et al [10]. They used a needle knife to incise the mucosa around a lesion and a snare to remove the area of mucosa including the lesion. This method did not become popular in contrast to strip biopsy EMR because of the complicated nature of the procedure, which demands high expertise and carries a high risk of bleeding and perforation. In late 1990, Hosokawa et al developed a new endoscopic electorosurgical knife that has a small insulated ceramic ball on its tip to prevent perforation (insulated-tip knife, IT knife, KD-610L; Olympus Medical Systems, Tokyo, Japan) [11]. Later on, Ono et al developed a technique of ESD using the IT knife [12]. This ESD technique consists of marking the margins of the area to be removed with the utilization of dye-spray chromoendoscopy (Fig. 2A, B); injection of a solution outside the marking dots (Fig. 2C); mucosal incision outside the marking dots with an IT knife (Fig. 2D); additional injection into the submucosa underneath the isolated area to achieve sufficient mucosal elevation (Fig. 2E); submucosal dissection with the IT knife (Fig. 2F, G); and retrieval of the specimen (Fig. 2H) [13]. The Intelligent Cut and Coagulation 200 (ICC-200; ERBE Elektromedizin GmbH, Tubingen, Germany) or VIO 300D (ERBE) was currently used as an electrical surgical unit in our endoscopy unit; the output settings are summarized in Table 3. After the removal of the lesion, the mucosal defect is washed out repeatedly and any adherent clots or suspicious protrusions are coagulated with a coagulation forceps to avoid delayed hemorrhage. With this method, the indicated mucosal lesion can be theoretically removed en bloc even it is large or scarred. Refinements of equipment or accessories, such as development of various knives (Fig. 3) [14-16], or use of a transparent hood or water-jet endoscope [17], have been carried on to improve practice of ESD. The knives that are used for gastric ESD are basically divided into two types. For one type, tip of the knife is covered with insulating material and a blade proximal to the tip is used for mucosal incision and submucosal dissection e.g. IT knife or SAFE knife (Fujifilm Medical Systems, Tokyo, Japan). This type of knife is safe because insulating material prevents perforation, although it demands characteristic manipulation for the procedures. Another type is the device that uses the tip of the knife for mucosal incision and submucosal dissection, such as the Triangle-tipped (KD-640L, Olympus Medical Systems), Hook (KD-620LR, Olympus Medical Systems), Dual (KD-650L, Olympus Medical Systems) and Flush (DK2618JN, Fujifilm Medical Systems) knife. Mucosal incision and submucosal dissection by using the tip of the knife is basically carried out under observation, thus the maneuver is easier than that of IT knife. However, careful manipulation to avoid perforation is necessitated for this type of knives. The Flush knife can emit a jet of water from the tip of its sheath to rinse mucus and blood clots and enables saline injection into the submucosa, thereby bypassing the need to change endoscopic devices [18].


Endoscopic management of early gastric cancer: endoscopic mucosal resection or endoscopic submucosal dissection: data from a Japanese high-volume center and literature review.

Uedo N, Takeuchi Y, Ishihara R - Ann Gastroenterol (2012)

Representative devices used for gastric endoscopic submucosal dissection. (A) Insulation-tipped diathermic knife-2; (B) ball-tipped flush knife; (C) hook knife; (D) hemostatic forceps (Coagrasper)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3959406&req=5

Figure 3: Representative devices used for gastric endoscopic submucosal dissection. (A) Insulation-tipped diathermic knife-2; (B) ball-tipped flush knife; (C) hook knife; (D) hemostatic forceps (Coagrasper)
Mentions: The original form of ESD was developed in the mid-1980s by Hirao et al [10]. They used a needle knife to incise the mucosa around a lesion and a snare to remove the area of mucosa including the lesion. This method did not become popular in contrast to strip biopsy EMR because of the complicated nature of the procedure, which demands high expertise and carries a high risk of bleeding and perforation. In late 1990, Hosokawa et al developed a new endoscopic electorosurgical knife that has a small insulated ceramic ball on its tip to prevent perforation (insulated-tip knife, IT knife, KD-610L; Olympus Medical Systems, Tokyo, Japan) [11]. Later on, Ono et al developed a technique of ESD using the IT knife [12]. This ESD technique consists of marking the margins of the area to be removed with the utilization of dye-spray chromoendoscopy (Fig. 2A, B); injection of a solution outside the marking dots (Fig. 2C); mucosal incision outside the marking dots with an IT knife (Fig. 2D); additional injection into the submucosa underneath the isolated area to achieve sufficient mucosal elevation (Fig. 2E); submucosal dissection with the IT knife (Fig. 2F, G); and retrieval of the specimen (Fig. 2H) [13]. The Intelligent Cut and Coagulation 200 (ICC-200; ERBE Elektromedizin GmbH, Tubingen, Germany) or VIO 300D (ERBE) was currently used as an electrical surgical unit in our endoscopy unit; the output settings are summarized in Table 3. After the removal of the lesion, the mucosal defect is washed out repeatedly and any adherent clots or suspicious protrusions are coagulated with a coagulation forceps to avoid delayed hemorrhage. With this method, the indicated mucosal lesion can be theoretically removed en bloc even it is large or scarred. Refinements of equipment or accessories, such as development of various knives (Fig. 3) [14-16], or use of a transparent hood or water-jet endoscope [17], have been carried on to improve practice of ESD. The knives that are used for gastric ESD are basically divided into two types. For one type, tip of the knife is covered with insulating material and a blade proximal to the tip is used for mucosal incision and submucosal dissection e.g. IT knife or SAFE knife (Fujifilm Medical Systems, Tokyo, Japan). This type of knife is safe because insulating material prevents perforation, although it demands characteristic manipulation for the procedures. Another type is the device that uses the tip of the knife for mucosal incision and submucosal dissection, such as the Triangle-tipped (KD-640L, Olympus Medical Systems), Hook (KD-620LR, Olympus Medical Systems), Dual (KD-650L, Olympus Medical Systems) and Flush (DK2618JN, Fujifilm Medical Systems) knife. Mucosal incision and submucosal dissection by using the tip of the knife is basically carried out under observation, thus the maneuver is easier than that of IT knife. However, careful manipulation to avoid perforation is necessitated for this type of knives. The Flush knife can emit a jet of water from the tip of its sheath to rinse mucus and blood clots and enables saline injection into the submucosa, thereby bypassing the need to change endoscopic devices [18].

Bottom Line: Moreover, the specimens obtained by ESD facilitate precise histological assessment of curability compared with the piecemeal specimens obtained by EMR.Accordingly, ESD has been established as a standard treatment for management of EGC in Japan.The long-term outcome of endoscopic management of EGC is based on: a) the accuracy of endoscopic diagnosis which defines the optimal treatment; b) endoscopist's expertise on methods for tumor removal (currently techniques of ESD); c) precise histological assessment of the resected specimen for curability; and d) surveillance endoscopy for early detection of metachronous multiple cancer.

View Article: PubMed Central - PubMed

Affiliation: Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan Endoscopic Learning and Training Center, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

ABSTRACT
As detection of early gastric cancer (EGC) has improved, endoscopic mucosal resection (EMR) has been adopted as a treatment option for small intramucosal carcinoma. Endoscopic submucosal dissection (ESD) has enabled high en bloc resection rate for small and large lesions, as well as those with scarring. Moreover, the specimens obtained by ESD facilitate precise histological assessment of curability compared with the piecemeal specimens obtained by EMR. Accordingly, ESD has been established as a standard treatment for management of EGC in Japan. The long-term outcome of endoscopic management of EGC is based on: a) the accuracy of endoscopic diagnosis which defines the optimal treatment; b) endoscopist's expertise on methods for tumor removal (currently techniques of ESD); c) precise histological assessment of the resected specimen for curability; and d) surveillance endoscopy for early detection of metachronous multiple cancer. Efforts to establish a standardized protocol for practice and training can accelerate dissemination of gastric ESD in regions where gastric cancer is highly prevalent, and may help endoscopists worldwide to adopt this technique for other organs in the digestive tract.

No MeSH data available.


Related in: MedlinePlus