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Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection.

Fujihara S, Mori H, Kobara H, Nishiyama N, Matsunaga T, Ayaki M, Yachida T, Morishita A, Izuishi K, Masaki T - Biomed Res Int (2014)

Bottom Line: However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES).The present paper aims to discuss the complementary role of ESD and the future development of EFTR.We focus on the possibility of achieving EFTR using the ESD method and closing devices.

View Article: PubMed Central - PubMed

Affiliation: Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.

ABSTRACT
Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for colorectal cancer. However, due to technical difficulties and an increased rate of complications, ESD is not widely used in the colorectum. In some cases, endoscopic treatment alone is insufficient for disease control, and laparoscopic surgery is required. The combination of laparoscopic surgery and endoscopic resection represents a new frontier in cancer treatment. Recent developments in advanced polypectomy and minimally invasive surgical techniques will enable surgeons and endoscopists to challenge current practice in colorectal cancer treatment. Endoscopic full-thickness resection (EFTR) of the colon offers the potential to decrease the postoperative morbidity and mortality associated with segmental colectomy while enhancing the diagnostic yield compared to current endoscopic techniques. However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES). Innovative methods and new devices for EFTR and suturing are being developed and may potentially change traditional paradigms to achieve minimally invasive surgery for colorectal cancer. The present paper aims to discuss the complementary role of ESD and the future development of EFTR. We focus on the possibility of achieving EFTR using the ESD method and closing devices.

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Related in: MedlinePlus

Endoscopic closure of an artificial ulcer with conventional clips and an OTSC system. (a) A large tumor, measuring 55 mm in diameter, located in the upper rectum. (b) A large mucosal defect after colorectal ESD. (c) Complete closure was performed using an OTSC system. (d) The endoscopic view at postoperative day 333.
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fig1: Endoscopic closure of an artificial ulcer with conventional clips and an OTSC system. (a) A large tumor, measuring 55 mm in diameter, located in the upper rectum. (b) A large mucosal defect after colorectal ESD. (c) Complete closure was performed using an OTSC system. (d) The endoscopic view at postoperative day 333.

Mentions: Closure of mucosal defects created during ESD is not routinely practiced in Japan, although some experts believe that such closure may decrease the risk of delayed bleeding and possibly perforation. At present, closure of the typically large ESD mucosal defect is impractical and technically challenging with currently available devices (e.g., hemoclips). The rate of perforation is higher than the rate of postoperative bleeding, but methods for preventing severe complications remain to be established for the management of postcolorectal ESD. Prophylactic closure with hemoclips may be effective in preventing the postoperative bleeding related to the endoscopic mucosal resection (EMR) of large (≥2 cm) sessile or flat colorectal lesions. In a cohort of polyps for which all polypectomies were performed using pure low-power coagulation current, the risk of delayed postpolypectomy hemorrhage decreased from 9.7% to 1.8% when comparing polypectomy sites that were not clipped with those that were completely clipped closed [35]. However, prophylactic clip closure has no benefit for the prevention of complications (postpolypectomy syndrome and perforation) other than delayed hemorrhage. We have reported that the prophylactic closure of large mucosal defects after colorectal ESD reduces the inflammatory reaction and relieves patient symptoms after colorectal ESD [36] (Figure 1). However, we could not obtain sufficient evidence to determine whether the prophylactic closure prevented delayed perforation and postoperative bleeding because of the small sample size and retrospective nature of the study. Future studies will require a larger sample size and a prospective study design.


Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection.

Fujihara S, Mori H, Kobara H, Nishiyama N, Matsunaga T, Ayaki M, Yachida T, Morishita A, Izuishi K, Masaki T - Biomed Res Int (2014)

Endoscopic closure of an artificial ulcer with conventional clips and an OTSC system. (a) A large tumor, measuring 55 mm in diameter, located in the upper rectum. (b) A large mucosal defect after colorectal ESD. (c) Complete closure was performed using an OTSC system. (d) The endoscopic view at postoperative day 333.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4022075&req=5

fig1: Endoscopic closure of an artificial ulcer with conventional clips and an OTSC system. (a) A large tumor, measuring 55 mm in diameter, located in the upper rectum. (b) A large mucosal defect after colorectal ESD. (c) Complete closure was performed using an OTSC system. (d) The endoscopic view at postoperative day 333.
Mentions: Closure of mucosal defects created during ESD is not routinely practiced in Japan, although some experts believe that such closure may decrease the risk of delayed bleeding and possibly perforation. At present, closure of the typically large ESD mucosal defect is impractical and technically challenging with currently available devices (e.g., hemoclips). The rate of perforation is higher than the rate of postoperative bleeding, but methods for preventing severe complications remain to be established for the management of postcolorectal ESD. Prophylactic closure with hemoclips may be effective in preventing the postoperative bleeding related to the endoscopic mucosal resection (EMR) of large (≥2 cm) sessile or flat colorectal lesions. In a cohort of polyps for which all polypectomies were performed using pure low-power coagulation current, the risk of delayed postpolypectomy hemorrhage decreased from 9.7% to 1.8% when comparing polypectomy sites that were not clipped with those that were completely clipped closed [35]. However, prophylactic clip closure has no benefit for the prevention of complications (postpolypectomy syndrome and perforation) other than delayed hemorrhage. We have reported that the prophylactic closure of large mucosal defects after colorectal ESD reduces the inflammatory reaction and relieves patient symptoms after colorectal ESD [36] (Figure 1). However, we could not obtain sufficient evidence to determine whether the prophylactic closure prevented delayed perforation and postoperative bleeding because of the small sample size and retrospective nature of the study. Future studies will require a larger sample size and a prospective study design.

Bottom Line: However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES).The present paper aims to discuss the complementary role of ESD and the future development of EFTR.We focus on the possibility of achieving EFTR using the ESD method and closing devices.

View Article: PubMed Central - PubMed

Affiliation: Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.

ABSTRACT
Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for colorectal cancer. However, due to technical difficulties and an increased rate of complications, ESD is not widely used in the colorectum. In some cases, endoscopic treatment alone is insufficient for disease control, and laparoscopic surgery is required. The combination of laparoscopic surgery and endoscopic resection represents a new frontier in cancer treatment. Recent developments in advanced polypectomy and minimally invasive surgical techniques will enable surgeons and endoscopists to challenge current practice in colorectal cancer treatment. Endoscopic full-thickness resection (EFTR) of the colon offers the potential to decrease the postoperative morbidity and mortality associated with segmental colectomy while enhancing the diagnostic yield compared to current endoscopic techniques. However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES). Innovative methods and new devices for EFTR and suturing are being developed and may potentially change traditional paradigms to achieve minimally invasive surgery for colorectal cancer. The present paper aims to discuss the complementary role of ESD and the future development of EFTR. We focus on the possibility of achieving EFTR using the ESD method and closing devices.

Show MeSH
Related in: MedlinePlus