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Endoscopic submucosal dissection (ESD) allows an “en bloc” resection with safety margins (R0 resection) regardless of the size of the lesion. However, while R0 brings a real benefit for the patient, it is not considered sufficient by many experts to justify the technical difficulties and the longer procedure time compared to piecemeal mucosectomy. The aims of this review are to provide several technical and strategical tips to help you save time and become comfortable during ESD procedures. ESD is divided into several intertwined phases: injection, incision, access to the submucosae, and submucosal dissection itself. During injection there are some mistakes that should not be made: a superficial injection, or on the contrary, a too deep injection. A good needle and good injection technique are mandatory. Some techniques, such as repeated injection or prolonged lifting solution, can help maintain the lift. After this step, mucosal incision can be made, taking care to have a good margin to allow an R0 resection. Starting the mucosal incision from a small point allows calibration of the depth of the incision and then obtaining a nice incision. Trimming is also very important to widen submucosal access. Then comes the submucosal dissection itself. Strategies such as the tunnel strategy or the pocket creation method can help to facilitate dissection, but more importantly, traction systems have become unavoidable, especially in the stomach and colon. Most common complications are bleeding and perforation, and they usually can be managed endoscopically.

Background and study aims This study evaluated the technical aspects of colorectal endoscopic submucosal dissection (ESD) with the Clutch Cutter (CC) (Fujifilm Co., Tokyo, Japan), a scissor-type knife, and the S-O clip (SO) as a traction clip, and compared the safety and efficacy to ESD using a needle-type knife. Patients and methods This was a single-center retrospective study. In Study 1, we evaluated 125 ESD patients: 60 using the SO and CC (SO group) and 65 using the CC (CC group). In Study 2, we evaluated 185 ESD patients: the CC group (N = 65) and 120 using the Flush knife BT-S (Flush group) (Fujifilm Co., Tokyo, Japan). In both studies, the clinicopathological features and therapeutic outcomes were compared using a propensity score-matched analysis. Results In 36 pairs of matched patients in Study 1, the rates of en bloc resection, R0 resection, perforation, and postoperative bleeding (POB) were 97.2 %, 88.9 %, 2.8 %, and 0 %, respectively, for the SO group and 100 %, 91.7 %, 0 %, and 0 % for the CC group (not significant). The mean procedure time for the SO group among less-experienced endoscopists was significantly shorter than in the CC group (42 vs. 65 minutes, P = 0.036). In 49 pairs of matched patients in Study 2, the rates of en bloc resection, R0 resection, perforation, and POB were 100 %, 95.8 %, 0 %, and 0 %, respectively, for the CC group and 98.0 %, 95.8 %, 0 %, and 2.0 % for the Flush group (not significant). The mean procedure time in the CC group among less-experienced endoscopists was significantly shorter than in the Flush group (52 vs. 67 minutes, P = 0.038). Conclusions CC and the combined use of CC and SO reduced colorectal ESD procedure time among less-experienced endoscopists.

Zusammenfassung Einleitung Eine optimale Zytoreduktion ist der wichtigste Prognosefaktor beim fortgeschrittenen Ovarialkarzinom. Obwohl Stadieneinteilung und Einschätzung der Operabilität durch Explorativ-Operation erfolgen, gilt die präoperative Computertomografie (CT) des Abdomens als Standard. Ziel dieser Studie ist die Überprüfung verschiedener CT-Parameter hinsichtlich der Prädiktion einer optimalen Zytoreduktion. Patienten und Methoden In die retrospektive Studie wurden 131 Patientinnen mit zwischen 2010 bis 2014 neu diagnostiziertem Ovarialkarzinom aufgenommen. Davon wurden n = 36 im FIGO-Stadium I bis IIB aus der Studie ausgeschlossen. Von den 95 Patientinnen mit FIGO-Stadium IIC bis IV lagen bei n = 75 präoperative CT-Abdomen vor. Die CT-Scans wurden einem verblindeten Review unterzogen. Die evaluierten 11 CT-Parameter wurden mittels χ2-Test und logistischer Regressionsanalyse hinsichtlich der Endpunkte makroskopischer Tumorrest sowie Tumorrest > 1 cm überprüft. Überlebensanalysen erfolgten mittels Kaplan-Meier-Methode und Log-Rank-Test. Ergebnisse Von 75 Patientinnen hatten 28 (37,3 %) eine vollständige Tumorresektion und 26 (34,7 %) Tumorreste ≤ 1 cm. Tumorreste > 1 cm fanden sich bei 21 Patientinnen (28 %), davon waren 5 nicht resektabel. Das Gesamtüberleben bei Tumorrest > 1 cm unterschied sich signifikant von der Gruppe mit makroskopischer Tumorfreiheit (p = 0,003) bzw. Tumorrest ≤ 1 cm (p = 0,04). Die CT-Parameter Tumorherde am Diaphragma, Mesokolon, Omentum majus, Peritoneum sowie Aszites korrelierten mit makroskopischem Tumorrest. In der multivariaten logistischen Regressionsanalyse war lediglich hinsichtlich der Prädiktion einer suboptimalen Tumorresektion (> 1 cm) der CT-Parameter intraparenchymatöse Lebermetastase statistisch signifikant (OR 8,04; 95 %-KI 1,57–42,4; p = 0,0134). Sensitivität, Spezifität, PPV und NPV betragen 37,5, 89,7, 66,7 und 72,2 %. Schlussfolgerung Obwohl mittels CT Abdomen Risikoparameter für suboptimale Tumorreduktion identifizierbar sind, ist wegen der geringen diagnostischen Genauigkeit die chirurgische Exploration mit histologischer Diagnosesicherung unverzichtbar.

Background and study aims Resecting large colorectal sessile tumors using endoscopic submucosal dissection (ESD) is challenging because of severe submucosal fibrosis. Previously, we reported that ESD strategy using the pocket-creation method (PCM) is useful for large colorectal sessile tumors, but there are no large studies reporting the effectiveness and safety of the PCM for resection of large colorectal sessile tumors. Patients and methods This was a retrospective review of 90 large colorectal sessile tumors in 89 patients who underwent ESD in our institution. Large colorectal sessile tumors were defined as polypoid lesions 20 mm or more in diameter. We divided them into PCM (n = 40) and conventional method (CM) groups (n = 50). The primary outcome measure was en bloc resection. The inverse-probability-treatment weighting (IPTW) approach was used to adjust for selection bias. Results Both PCM and CM achieved high en bloc resection (100 % vs. 94 %, non-adjusted P = 0.25, IPTW-adjusted P = 0.19) and R0 resection rates (88 % vs. 78 %, non-adjusted P = 0.28, IPTW-adjusted P = 0.27). When PCM was used, the rate of pathologically negative vertical margins was significantly greater than with the CM (IPTW-adjusted P = 0.045). The dissection time was significantly shorter (IPTW-adjusted P = 0.025) and dissection speed faster (IPTW-adjusted P = 0.013) using the PCM than when the CM was used. There was no significant difference in the incidence of adverse events (intraprocedural perforation and delayed bleeding, IPTW-adjusted P = 0.68). Conclusion Although en bloc resection and R0 resection rates were similar, PCM significantly increased the rate of negative vertical margins with rapid dissection for treatment of large colorectal sessile tumors.

Background Endoscopic submucosal dissection (ESD) of residual or locally recurrent (RLR) colonic lesions after previous endoscopic mucosal resection (EMR) is an attractive but challenging technique. The present study aimed to evaluate the effectiveness and safety of ESD with double clip and rubber band traction (DCT-ESD) of RLR colonic lesions. Methods We retrospectively analyzed all consecutive DCT-ESD procedures for RLR colonic lesions (rectum excluded) performed in two French centers. The frequency of en bloc and R0 resections, procedure speed, additional surgery, and complications were evaluated. R0 resection was also used to investigate the learning curve. Results Among the 53 resections, 49 (92.5 %) were performed en bloc and 42 (79.2 %) achieved R0. The median procedure speed was 21 mm2/min. There were four (7.5 %) intraoperative perforations and one delayed bleeding; these were successfully treated endoscopically. There was no salvage surgery for complications. The R0 rate increased from 16/26 (61.5 %) for the first 26 procedures to 26/27 (96.3 %, P = 0.002) for the last 27 procedures. Conclusions DCT-ESD appears to be a safe and effective treatment for RLR colonic lesions after EMR.

Background and study aims Endoscopic submucosal dissection (ESD) of superficial gastric lesions involving the pyloric ring is difficult. The pocket-creation method (PCM) with a small-caliber-tip transparent hood can overcome this difficulty by compressing the pyloric sphincter applying both traction and counter-traction. The aim of this study is to clarify the usefulness of the PCM for ESD of superficial gastric neoplasms involving the pyloric ring compared to the conventional method (CM). Patients and methods From October 2006 to August 2019, 66 gastric lesions requiring duodenal submucosal dissection beyond the pyloric ring in 66 patients were resected. The CM was mainly performed in the first period (CM group, n = 46) and the PCM in the second period (PCM group, n = 20). We retrospectively reviewed their medical records. Results Although no significant differences were observed in en bloc resection rates between the two groups, the PCM group had a significantly higher R0 resection rate than the CM group (P = 0.047). There were no holes in resected specimens in the PCM group while three specimens in the CM group had a hole. The dissection speed in the PCM group tended to be higher than in the CM group, although it did not reach statistical significance (P = 0.148). No significant differences were observed for the incidence of adverse events. Conclusions This is the first study reporting the advantages of the PCM over the CM for ESD of gastric lesions involving the pyloric ring. We believe that the PCM is an effective strategy to compress the pyloric sphincter and facilitates R0 resection.

Background and study aims Surgery is the standard treatment for colon tumors associated with diverticulum. Use of endoscopic submucosal dissection (ESD) to treat such tumors is controversial. The aim of this study was to assess the safety and feasibility of ESD in treating superficial colorectal tumors situated near or involving diverticulum. Patients and methods Consecutive patients from two referral centers who had colorectal tumors near or involving diverticulum treated by ESD were retrospectively studied. Clinicopathological characteristics and clinical outcomes were analyzed. Results Of the 12 patients studied, six had tumors near diverticulum and six had tumors involving diverticulum. The overall en-bloc R0 resection rate, median tumor size and procedure time were 67 %, 26.5 mm (range, 15 – 80 mm) and 110 minutes (range, 50 – 220 minutes), respectively. For tumors near diverticulum group, the en-bloc R0 resection rate was 100 % and no adverse events (AEs) or residual/recurrent tumors were observed. In contrast, for intradiverticular tumors group, the en-bloc R0 resection rate was low at 33 %, and one AE (perforation) was observed. The diverticula were ≥ 6 mm in diameter in the patients with incomplete resection. However, all but one diverticulum was unrecognized before ESD. Two residual tumors were detected at the 12-month surveillance and one required surgery. Conclusions This case series indicates that ESD is safe and feasible for treating colorectal tumors near a diverticulum and might be feasible for tumors involving a diverticulum smaller than 6 mm. Selection for smaller diverticulum size may contribute to higher en-bloc R0 resection rates.

Background and study aims Endoscopic submucosal dissection (ESD) has become the standard treatment for colorectal ESD, but large colorectal tumors remain difficult to remove. We developed a new method, called the palisade technique, by modifying the multiple tunneling technique. In this method, a palisade of submucosal tissue is left beneath the tumor to anchor a dissected specimen, maintaining effective submucosal traction. Patients and methods The study included 11 patients with large colorectal tumors that were over half the circumference of the colorectal lumen which were treated using the palisade technique from August 2017 to October 2019. Overall resection outcomes were assessed. Results All 11 lesions were removed en bloc. The R0 resection rate was 45.6 % because of marginal burning of the specimen, but no local recurrence was found after a median observation period of 31 months. The median submucosal dissection time (SDT) and submucosal dissection speed (SDS) were 170 minutes and 23.1 mm2/min, respectively. One case of post-ESD hemorrhage was successfully managed endoscopically, and two cases of post-colorectal ESD coagulation syndrome were managed conservatively. Conclusion The palisade technique can be an effective and safe technique for treating large colorectal tumors that extend over half the luminal circumference.

Background and study aims Colorectal polyps involving the appendiceal orifice (AO) are difficult to resect with conventional polypectomy techniques and therefore often require surgical intervention. These appendiceal polyps could potentially be removed with endoscopic full-thickness resection (eFTR) performed with a full-thickness resection device (FTRD). The aim of this prospective observational case study was to evaluate feasibility, technical success and safety of eFTR procedures involving the AO. Patients and methods This study was performed between November 2016 and December 2017 in a tertiary referral center by two experienced endoscopists. All patients referred for eFTR with a polyp involving the AO that could not be resected by EMR due to more than 50 % circumferential involvement of the AO or deep extension into the AO were included. The only exclusion criterion was lesion diameter > 20 mm. Results Seven patients underwent eFTR for a polyp involving the AO. All target lesions could be reached with the FTRD and retracted into the device. Technical success with an endoscopic radical en-bloc and full-thickness resection was achieved in all cases. Histopathological R0 resection was achieved in 85.7 % of patients (6/7). One patient who previously underwent an appendectomy developed a small abscess adjacent to the resection site, which was treated conservatively. Another patient developed secondary appendicitis followed by a laparoscopic appendectomy. Conclusion This small exploratory study suggests that eFTR of appendiceal polyps is feasible and can offer a minimally invasive approach for radical resection of these lesions. However, more safety and long-term follow-up data are needed to evaluate this evolving technique.

Background and study aims The endoscopic submucosal dissection (ESD) of cancerous and precancerous lesions in the gastrointestinal (GI) tract is an effective but difficult-to-learn procedure, especially for Western endoscopists. We developed a step-up training protocol and evaluated its outcome on a single endoscopist using specific performance measures. Patients and methods The training protocol included a 12-month period of 50 observational and supervised ESD cases as well as 24 animal procedures. After completion of the protocol, ESD competency was evaluated in the first 30 independent ESD cases. Majority of lesions were located in the stomach and rectum. Performance measures included R0-resection rate, complication rate and resection speed. Results R0 resection rate was 93 %, complication rate was 7 % and median resection speed was 6,77 cm2/h. 1 case of delayed perforation with subsequent hemicolectomy occurred in the descending colon. Conclusion The ESD step-up training protocol used in this study on a single endoscopist showed excellent outcomes for lesions in the rectum and stomach. However, ESD training in the upper colon remains a challenge.

Background Duodenal endoscopic submucosal dissection (ESD) remains technically challenging, with a high risk of severe adverse events. Because exposure of the duodenal post-ESD mucosal defect to pancreatic juice and bile acid reportedly induces delayed perforation and bleeding, we examined whether defect closure using an over-the-scope clip (OTSC) system was useful for preventing postoperative adverse events. Methods From April 2016 to February 2017, a total of 50 consecutive patients with superficial non-ampullary duodenal epithelial tumors (SNADETs) larger than 10 mm, with no more than semi-circumferential spread, were prospectively enrolled in this study. All of the lesions were treated by experienced ESD operators and the post-ESD mucosal defect was closed using OTSCs. Results All of the SNADETs were completely removed by ESD, with an R0 resection rate of 88.0 %. The mean procedure and closure times were 67.3 ± 58.8 minutes and 9.8 ± 7.2 minutes, respectively. Although complete defect closure was achieved in 94.0 % of the patients (47/50), two patients required surgical conversion. Delayed perforation occurred in only one patient (2.1 %), who did not have successful closure of the defect, as misplacement of the OTSC exposed the muscle layer. Meanwhile, delayed bleeding occurred in three patients (6.3 %); however, the bleeding was easily controlled using endoscopic coagulation. The mean duration of postoperative hospitalization was 5.5 ± 7.2 days. Conclusions Prophylactic defect closure using OTSCs may be effective in reducing severe adverse events after duodenal ESD.

Background and study aim Single-tunnel endoscopic submucosal tunnel dissection (ESTD) has shown promising preliminary efficacy for large superficial esophageal squamous cell neoplasms (SESCNs). This study reports the outcomes of both single- and double-tunnel ESTD for large SESCNs, and compares the efficiency of the two techniques for treating circumferential SESCNs. Patients and methods 46 patients with large SESCNs underwent ESTD at a single hospital between October 2011 and March 2016. Relevant clinical data were retrospectively collected and analyzed. Results For all patients, the en bloc and R0 resection rates were 95.7 % and 82.6 %, respectively. Perforation and cardiac mucosal laceration were detected in 2.2 % (1/46) and 6.5 % (3/46) of the procedures, respectively. Postoperative stenosis occurred in 12 patients (26.1 %). Of the 18 patients with circumferential lesions, those who received a double-tunnel ESTD procedure (n = 6) underwent dissection faster than those who had a single-tunnel ESTD procedure (n = 12) (0.32 vs. 0.12 cm2/min; P = 0.02). Conclusion ESTD was effective for large SESCNs. The double-tunnel ESTD appeared to decrease operative time compared with single-tunnel ESTD for circumferential lesions.

Background and study aims Endosurgical devices with injection function have been reported to decrease endoscopic submucosal dissection (ESD) operation times for experts, but the efficacy of these devices for inexperienced endoscopists is unclear. The aim of this study was to evaluate the feasibility of ESD using a novel ESD knife (DN-D2718B). Patients and methods This is a single-center prospective pilot clinical feasibility study. Patients diagnosed with superficial gastrointestinal neoplasms were enrolled. A pre-specified group of ESD trainees with ESD experience on a porcine gastric model and fewer than 30 cases of ESD in their selected fields performed ESD under expert supervision, using the DN-D2718B. En bloc resection rates, R0 resection rates, procedure times, and incidence of intra-operational/post-operational adverse events were assessed. Results Between June 2015 and January 2016, 13 esophageal, 27 gastric, and 14 colorectal ESD cases were performed per-protocol with mean resection speeds of 10.2, 12.0, and 15.5 mm2/min, respectively. There were no intra-operational complications. Conclusion ESD with this novel knife is feasible even when performed by non-experts.

Zusammenfassung Hintergrund Weichteil- und Osteosarkome sind häufig mit Lungenmetastasen vergesellschaftet. Patienten sind für eine kurative Metastasektomie geeignet, wenn der Primärtumor erfolgreich reseziert worden ist, sie lediglich pulmonale Metastasen aufweisen und die funktionelle Operabilität sowie die vollständige Metastasenresektion gewährleistet sind. Material und Methoden Systematische Literaturrecherche und qualitative Analyse aller ab dem 01.01.2010 publizierten Fallserien über Patienten nach vollständiger Sarkomresektion und anschließender Lungenmetastasenchirurgie. Zielparameter waren operative Befunde, Überlebensdaten und Prognosefaktoren. Ergebnisse Die Lungenmetastasenchirurgie ermöglicht ein medianes Postmetastasektomieüberleben von 8,76 bis 69,9 Monaten. Postoperativ werden nach Metastasektomie 5-Jahres-Überlebensraten zwischen 21,7 und 56,8% erreicht, dabei hängt die Prognose maßgeblich von der vollständigen Resektion aller Lungenmetastasen ab. Intrapulmonale Rezidive können nach kritischer Indikationsstellung reseziert werden und mit einer günstigen Prognose verbunden sein. Schlussfolgerungen Für selektionierte Patienten mit Osteosarkomen und isolierter Lungenmetastasierung sollte die Metastasektomie die Therapie der Wahl sein. Patienten mit Weichteilsarkomen und isolierter pulmonaler Metastasierung können bei richtiger Indikationsstellung von einem chirurgischen Eingriff profitieren.

Background and study aims The pocket-creation method (PCM) is a novel strategy for endoscopic submucosal dissection (ESD). The aim of this study is to determine the efficacy of the PCM for colorectal laterally spreading tumors, non-granular type (LST-NG). Patients and methods The records of 126 consecutive patients with colorectal LST-NG who underwent ESD between April 2012 and July 2015 were retrospectively reviewed. Patients were divided into PCM (n = 73) and conventional method (CM) (n = 53) groups. Results The en bloc resection rate in the PCM group was significantly higher than in the CM group (100 % [73/73] vs. 92 % [49/53], P = 0.03). The en bloc resection rate with severe fibrosis was higher in the PCM group than in the CM group (100 % [3/3] vs. 60 % [3/5]). The R0 resection rate for the two groups was not statistically significantly different (93 % [68/73] vs. 91 % [48/53], P = 0.74). The perforation rate in the PCM group was lower than in the CM group although not statistically significantly less (0 % 0/73 vs. 4 % 2/53, P = 0.18). For lesions resected en bloc, dissection speed for the PCM group was significantly faster than for the CM group (median [IQR], 19 [13 –24] vs. 14 [10 – 22] mm2/min, P = 0.03). Conclusion ESD using PCM achieves a reliable and safe resection of colorectal LST-NG.

Background and study aims ESD in the colon is more challenging technically than in other locations. Here, we report the first comparative case series of colon ESD using a systematic countertraction strategy using two clips and a rubber band. Patients and methods Retrospective comparative study of classic versus countertraction colon ESD performed in colon ESD cases collected prospectively at Lyon Edouard Herriot Hospital and Limoges University Hospital from January 2016 until December 2017. Results The study included 192 cases (control = 76, countertraction = 116). Countertraction using the double clip and rubber band technique versus the control group resulted in a significant decrease in the procedure time (94.7 vs. 117 min; P = 0.004) and significant increases in procedure speed (28.2 vs. 16.7 mm2/min; P At an individual operator point of view, results varied between operators but the double clip countertraction strategy significantly increased the en bloc resection rate, R0 resection rate, and speed of dissection for each of the 4 operators. Conclusion Systematic countertraction using a double clip and rubber band facilitates colon ESD. This strategy should become the standard for colon ESD.

Background and study aims Despite widespread use of cold snare polypectomy (CSP), the R0 resection rate is not well documented. We perform extended CSP, resecting polyps with a > 1 mm circumferential margin. The aim of this study is to compare the R0 resection rate of extended CSP with conventional CSP and to assess safety. Patients and methods From April 2014 to September 2016, 712 non-pedunculated colorectal polyps, Results We divided lesions into conventional CSP (n = 263) and extended CSP groups (n = 449). The baseline characteristics of these two groups were not significantly different in univariate or multivariate analyses. Sessile polyps comprised 94 % (668/712), and the remaining were flat-elevated polyps. Mean size of polyps (±standard deviation) was 4.2 ± 1.5 mm. The most frequent pathology was low grade adenoma (97 %, 689/712). The R0 resection rate was significantly higher in the extended CSP group (439/449 [98 %]) than in the conventional CSP group (222/263 [84 %], P Conclusions Extended CSP results in a higher R0 resection rate compared with conventional CSP. Extended CSP did not result in a higher rate of delayed bleeding or perforation. Extended CSP is a safe and promising procedure for endoscopic resection of non-pedunculated colorectal polyps

Hintergrund: In grosen Serien liegt die Haufigkeit einer R1-Resektion bei 20–40 % und stellt somit ein ernstzunehmendes Problem bei der Resektion von Klatskin-Tumoren dar. Methoden: Literaturubersicht zur Bedeutung der R1-Resektion bei Klatskin-Tumoren und zu moglichen chirurgischen Optionen zur Steigerung der Rate an kompletten Tumorresektionen. Ergebnisse: Bei der Planung des Resektionsverfahrens von Klatskin-Tumoren mussen anatomische Pradilektionsstellen fur eine R1-Resektion berucksichtigt werden. Bei der Operationsplanung spielen vor erweiterten rechtsseitigen Hemihepatektomien insbesondere Aspekte der Leberfunktion eine wichtige Rolle. Aufgrund des hohen Verlusts an funktionellem Leberparenchym ist meist eine Pfortaderembolisation der Gegenseite anzuraten. Bei linksseitigen Hemihepatektomien ist insbesondere das pra- und intraoperative Management der rechten Leberarterie von zentraler Bedeutung. Diese weist bei typischem Verlauf oft einen langstreckigen Tumorkontakt uber 180° der arteriellen Zirkumferenz auf, obwohl sich histologisch selten eine Gefasinvasion findet. Trotzdem besteht das hohe Risiko einer manifesten oder okkulten R1-Resektion. In ausgewahlten Fallen kann daher eine arterielle Resektion erwogen werden. Dies erhoht allerdings das Komplikationsrisiko und muss daher individuell abgewogen werden. Nach Arterienresektion ist entweder die direkte Rekonstruktion moglich, alternativ kann auch eine arterielle Transposition oder ein Gefasinterponat zur Anwendung kommen. Als Reserveverfahren stehen zusatzlich die praoperative arterielle Embolisation ohne Rekonstruktion sowie die Arterialisierung der Pfortader zur Verfugung. Bei den beiden letzteren Verfahren ist die Gefahr von biliaren Komplikationen hoch. In ausgewahlten Fallen kann bei irresektablen und lymphknotennegativen Klatskin-Tumoren eine Lebertransplantation erwogen werden. Schlussfolgerung: Trotz vieler Weiterentwicklungen in den chirurgischen Techniken stellt die R1-Resektion von zentralen Gallengangskarzinomen weiterhin ein Problem dar, das durch das Fehlen evidenzbasierter adjuvanter Therapiemasnahmen noch aggraviert wird.

Unique anatomical features render endoscopic resection for rectal tumors extending to the dentate line (RTDL) technically challenging. The aim of this study was to evaluate the feasibility of endoscopic submucosal dissection (ESD) for RTDLs.This retrospective study compared ESD for RTDLs with proximal rectal tumors between September 2002 and June 2012. En bloc resection rate, R0 resection rate, complications, and tumor recurrences were assessed.A total of 45 RTDLs (median age 69 years; 15 males; median lesion size 38.4 mm) and 94 proximal rectal tumors were identified. En bloc resection and R0 resection rates were 95.6 % (43/45) and 53.3 % (24/45), respectively. The perforation rate was 4.4 %. Compared with proximal rectal ESD, ESD for RTDLs showed longer procedure time (104 vs. 60 minutes; P 0.001), lower R0 resection rate (53.3 % vs. 70.2 %; P = 0.019), and more frequent high grade fever (22.2 % vs. 4.3 %; P = 0.002). No residual adenoma was observed at the first surveillance colonoscopy. Recurrence rate did not differ significantly between the two groups.ESD for RTDLs demonstrated safety and effectiveness comparable to ESD in proximal rectal lesions.

ZusammenfassungLeiomyosarkome machen mit nur 6 % einen kleinen Bereich der Weichteiltumore aus. Davon sind ca. 20 % gefäßassoziiert und vorwiegend im Bereich der Vena cava inferior beschrieben (1–4). Es handelt sich um einen äußerst aggressiven Tumor, der insbesondere an der unteren Extremität unspezifische Beschwerden bereitet. Primär bei nicht vorlie-gender Metastasierung ist die komplette Resektion des Tumors mit Sicherheitsabstand die Therapie der Wahl, die das Langzeitüberleben der Patienten positiv beeinflusst (2, 5, 6). Jedoch mehr als 50 % der Patienten haben bereits bei Diagnosestellung pulmonale oder hepatische Metastasen (1–3). Im Allgemeinen ist eine interdisziplinäre Zusammenarbeit von den Chirurgen, Pathologen und Onkologen sowie Radiologen gefordert.Dieses Fallbeispiel beschreibt einen 74-jährigen, männlichen Patienten mit einer seit etwa einem Jahr bestehenden lokalen Schwel-lung am proximalen linken Unterschenkel. Mit Hilfe eines Schnellschnittverfahrens konnte histopathologisch ein Leiomyosarkom mit mäßiger Differenzierung nachgewiesen werden. Es erfolgte die radikale Tumorexzision mit erfolgreicher R0-Resektion.

A resection is considered to be R0 when the pathological examination confirms that the edges of the resected specimen are free of disease. A resection is curative when the patient is cured by the endoscopic treatment without need for further surgery or chemoradiation therapy. In the colon for example, the definition of the curative R0 resection is quite simple: a strict R0 is defined by an 'en bloc' specimen with normal mucosa on the edges when examined histologically. The treatment is considered to be curative if the resection is R0 with an invasion depth less than 1000 µm in the submucosa, without lymphatic or venous emboli, without budding, and with a differentiated carcinoma. The situation is far more complex in the neoplasia developed on Barrett’s esophagus (BE) since different degrees of neoplasia are possible with different prognosis and treatment strategies. At present, we do not have any consensus on the definition of R0 and curative resections for BE neoplasia (Fig. 1 a). This editorial aims to discuss various definitions of the R0 resection and their clinical impact. We shall also discuss the literature available to choose the best criteria to define resection curativeness. Fig. 1 Schematic representation of the different R0 resections. a Neoplasia representation; b Colon-like R0; c Intestinal metaplasia R0; d LGD or less R0; e HGD or less R0; f Flat components R0. IM, intestinal metaplasia; LGD, low grade dysplasia; ...

Endoscopic submucosal dissection (ESD) is being increasingly used for superficial esophageal cancers. However, esophageal ESD is technically difficult, time consuming, and less safe compared with endoscopic mucosal resection (EMR). To perform ESD safely and more efficiently, various types of knives have been developed. This study compared the efficacy of our newly developed device, Mucosectom2, with that of conventional devices for esophageal ESD.Between May 2007 and February 2011, ESD was performed for 172 esophageal lesions. Of these, 120 lesions were treated by conventional devices only, whereas 52 lesions were treated by conventional devices and the Mucosectom2. Procedure time, en bloc and R0 resection rates, and adverse events were retrospectively compared between the conventional and Mucosectom2 groups.The median procedure time was 48.0 minutes in the conventional group and 21.5 minutes in the Mucosectom2 group; the procedure time was significantly shorter in the Mucosectom2 group than in the conventional group (P0.0001). The en bloc and R0 resection rates were lower in the conventional group than those in the Mucosectom2 group, although these differences were not significant. The rate of exposure of the muscle layer in the Mucosectom2 group was significantly lower than in the conventional group (P = 0.04). The rates of perforation and postoperative bleeding were not significantly different between the two groups.This feasibility study suggests that, compared with conventional ESD devices, the Mucosectom2 may decrease the time required for esophageal ESD. Although our groups appeared comparable, they were studied at different times. Endoscopic expertise and endoscope quality may have differed during these periods, thereby affecting the results of our study. A prospective trial is therefore required to confirm our results.

Background and study aims: Colorectal endoscopic submucosal dissection (ESD) is an attractive method for en bloc resection of larger flat neoplastic lesions. Experience with this method is limited in the Western World. Patients and methods: A total of 182 consecutive flat or sessile colorectal lesions (cecum n = 43; right-sided colon n = 65; left-sided colon n = 11, rectum: n = 63) with a size > 20 mm (mean 41.0 ± 17.4 mm) were resected in 178 patients. The data were recorded prospectively. Results: ESD was technically feasible in 85.2 % of patients with a mean procedure time of 127.5 min (± 99.8) min and a complication rate of 11.5 % (microperforation 9.3 %, delayed bleeding 2.7 %, no case of emergency surgery, 30-day mortality rate 0 %). For 155 successfully completed procedures the en bloc and R0 resection rates were 88.4 and 62.6 %. Efficacy was better for smaller lesions (20 mm to 49 mm; n = 131) than for larger lesions (50 mm to 140 mm; n = 51) with R0 rates of 70.8 vs. 40.5 % (P 20 mm. Results are satisfactory for lesions up to 50 mm. ESD for larger lesions was associated with low R0 resection rates and very long procedure times. The clinical consequences of microperforations were minor and do not argue against the spread of ESD in the West. Meeting presentations: The data were presented in part at DDW 2014, Chicago IL, USA (Gastrointest Endosc 2014; 79: AB536)

Background and study aims: A standard training system for endoscopic submucosal dissection (ESD) remains to be established. In this study, we evaluated the validity of our training program for gastric ESD. Patients and methods: Four trainees performed gastric ESD for a total of 117 lesions in 107 patients (27 to 30 consecutive lesions per trainee) at a tertiary referral center during 2 years in the training program. Trainees, who already had the fundamental skills and knowledge needed for ESD, each assisted at 40 gastric ESD procedures, then in 20 cases applied post-ESD coagulation (PEC) to gastric mucosal defects; they then began to perform ESD, starting with gastric antral lesions. Treatment outcomes, including mean procedure time, and rates of en bloc resection, en bloc plus R0 resections, complications, and self-completion, were evaluated, for the initial 15 and subsequent 12 to 15 cases. Results: Overall rates of en bloc resection and en bloc plus R0 resection were as high as 100 % and 96.6 %, respectively. Regarding complications, seven cases of delayed hemorrhage (6.0 %) and three cases of perforation (2.6 %) occurred; all complications were solved endoscopically. The most frequent reason for operator change was lack of submucosal dissection skill. The self-completion rate was more than 80 % even in the early period, and did not increase for later cases. Conclusions: Our training system enabled novice operators to perform gastric ESD without a decline in clinical outcomes. Key features of this training are prior intensive learning and actual ESD during the learning period under expert supervision.

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

BACKGROUND: Gastric carcinoma is often diagnosed at UICC stage 3 b or 4. R0 resection can be achieved only in very few such cases. Even for these patients the 5-year survival rate is less than 5 %. Surgical palliation is traditionally reserved for the treatment of severe tumour complications not responding to other forms of treatment. PATIENTS AND METHODS: We report on 21 patients who underwent palliative resection for gastric carcinoma at our institution between 2004 and 2007. Ten of these were assigned to palliative surgical treatment pre-operatively while this choice was made for 11 patients on the grounds of the intra-operative findings. We performed 17 gastrectomies, 3 proximal gastric resections and one distal gastric resection. RESULTS: It has been shown that the patients have an improved overall survival time as compared to patients who received non-surgical treatment. The perioperative risk was reasonable when pa-tients were carefully selected. Median survi-val for resected patients was 16 months. 80 % of pa-tients were alive after 6 months and approxi-mate-ly 60 % of patients were alive after 12 months. The peri-operative mortality was 0 % with a mean hospi-tal stay of 12 days. All patients were discharged home with proper bowel passage and analgesia as individually required. CONCLUSIONS: We are convinced that palliative gastric resection provides a pronounced survival benefit over any other palliative treatment options. Patients also have an improved quality of life.