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Background and Aim Propofol has been suggested to be superior to benzodiazepines when used as a sedative agent for endoscopic examination. The aim of the present study was to systematically evaluate the safety and efficacy of propofol sedation for endoscopic submucosal dissection ( ESD). Methods Pub Med, the Cochrane library, and the Igaku- Chuo- Zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data from the eligible studies were combined to calculate pooled odds ratios ( OR) of developing restlessness, full awakening at 1 h post- ESD, hypoxia, and hypotension. Results We identified three randomized trials (298 patients) from the database search. Compared with traditional sedative agents, the pooled OR of restlessness and full awakening at 1 h post- ESD with propofol sedation were 0.41 (95% confidence interval [ CI]: 0.21-0.81) and 8.59 (95% CI: 4.29-17.2), respectively, without significant heterogeneity. Compared with traditional sedative agents, the pooled OR of hypoxia and hypotension with propofol sedation were 1.13 (95% CI: 0.58-2.21) and 0.92 (95% CI: 0.25-3.41), respectively, indicating no significant differences between the groups. Conclusion Propofol sedation during ESD is more effective as compared with traditional sedative agent. The risk of complications is similar. [ABSTRACT FROM AUTHOR]

Background and Aim: We analyzed the characteristics of gastrointestinal neuroendocrine tumors and examined the outcomes and safety of modalities in rectal neuroendocrine tumors. Methods: Between 2007 and 2011, a total of 91 patients with gastrointestinal neuroendocrine tumors were retrospectively reviewed in terms of the characteristics of tumors. Results: Sixty-six patients had rectal neuroendocrine tumors and underwent endoscopic mucosal resection (EMR, n = 29), endoscopic submucosal dissection (ESD, n = 23), or transanal endoscopic microsurgery (TEM, n = 14). The complete resection rate was higher in the ESD group (82.7%) and in the TEM group (100%) compared to the EMR group (65.5%) (P < 0.046). The complication rate was higher in the ESD group (47.8%) than in the EMR group (18.5%) (P = 0.003). No local tumor recurrence was observed in all patients, regardless of the procedure, during the median follow-up period of 21.5 ± 13.5 months. Conclusions: ESD achieved a higher complete resection rate than EMR and comparable to TEM. Tumor recurrence was not observed in the endoscopic resection and TEM groups, regardless of the completeness of resection. Small neuroendocrine tumors of the gastrointestinal tract can be managed reliably with both endoscopic resection and TEM. [ABSTRACT FROM AUTHOR]

Background and Aim: Colorectal endoscopic submucosal dissection (ESD) is widely carried out, but is still considered difficult. In 2010, a tumor size of =50 mm and less experience in colorectal ESD were reported as independent risk factors for complications such as perforation, delayed perforation and postoperative bleeding. In order to overcome such difficulties, we developed a scissors-type grasping device and reported the treatment results of a multicenter study. The aim of the present study was to investigate therapeutic outcomes of colorectal ESD of different tumor sizes. Methods: Group A (134 tumors): tumor size <50 mm, and Group B (16 tumors): tumors ≥50 mm. All tumors were removed by ESD. We retrospectively evaluated the clinicopathological features of the tumors and the treatment results. Results: Age, sex, tumor location and histopathological diagnosis were not different between the two groups. Laterally spreading tumor non-granular type was more often observed in Group A (64/134, 47.8%) than in Group B (0/16, 0%). Procedure time was significantly longer in Group B (Group A: 38 min; Group B: 86 min, P < 0.01). However, procedure speed was significantly faster in Group B (Group A: 0.21 cm²/min; Group B: 0.37 cm²/min, P < 0.01). No complications were observed in either group. The en bloc resection rate, en bloc R0 resection rate, and en bloc curative resection rate were similar between the groups with no significant differences. Conclusions: Procedure speed for Group B was faster than that for Group A. Group B was treated as safely as Group A. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data pertaining to the natural history and outcomes of patients with well-differentiated rectal carcinoids. Objective: To correlate endoscopic size with the natural history and outcome. Design: Retrospective study. Setting: Single tertiary referral center. Patients: Eighty-seven patients with endoscopically identified well-differentiated rectal carcinoid tumors. Intervention: Colonoscopy. Main Outcome Measurements: Prevalence of metastasis at diagnosis, disease progression, and survival. Results: Metastasis was present at diagnosis in 3%, 66%, and 73% of tumors measuring ≤10 mm, 11 to 19 mm, and ≥20 mm, respectively. Metastasis was predicted with 100% sensitivity and 87% specificity using an endoscopic lesion size ≥9 mm. In patients without identified metastasis, 64% were identified during screening colonoscopy. Within this select cohort, subsequent metastasis was discovered only at distant extra pelvic sites, in 1.6%, 50%, and 100% of patients with tumors initially measuring ≤10 mm, 11 to 19 mm, and ≥20 mm, respectively. The carcinoid related 5- and 10-year survival rates for locally confined disease were 96%. The corresponding survival rates for local and advanced metastatic disease were 60% and 35%, respectively. Limitations: Subjective estimation of tumor size, mitotic index or Ki-67 labeling index not reported, and lack of formal and standardized baseline staging algorithm and surveillance program. Conclusions: The clinical behavior of 11- to 19-mm tumors appears to mimic that of larger (>20 mm) lesions with respect to the presence of metastasis at diagnosis and disease progression. Therefore, if local therapy is contemplated, we propose to make a distinction between ≤10-mm and 11- to 19-mm tumors, favoring an aggressive staging and management protocol for 11- to 19-mm carcinoid tumors. [Copyright &y& Elsevier]

Background and Aim Endoscopic submucosal dissection ( ESD) is a complex procedure and is associated with significant risks. The aims of this pilot study were to study feasibility and procedural times of gastric ESD using a novel gel and endoscopic scissors in a porcine model. Methods Simulated 3-cm gastric submucosal lesions were created in a porcine model. Subsequently, viscous gel was injected into the created bleb. A needle knife was used to create an initial incision when needed. Endoscopic scissors were then used for circumferential incision around the simulated submucosal lesions. The inserted coil (i.e. submucosal lesion) was then removed. The submucosal surface was carefully examined for signs of injury. Procedural times were recorded. Results ESD was carried out in four consecutive pigs using the 'Scissorhands' technique. A small submucosal incision was created a using needle knife in the first pig and electrocauterywas not used in the remaining three pigs. Circumferential incision using the scissors was done successfully in all pigs. Submucosal dissection was not required in any case. 'Auto-dissection' of created lesions by the gel was noted to be complete in all cases. Inserted coils were noted in the submucosal space during all experiments and were removed. All lesions were successfully resected en bloc. The mean procedure time was 19 min (range 13-22 min). Conclusion The combined technique of endoscopic scissors for circumferential incision and viscous gel for submucosal dissection permitted easy, safe and efficient gastric ESD. Electrocautery may be avoided and its consequent adverse events (e.g. perforation). [ABSTRACT FROM AUTHOR]

Primary esophageal mucosa-associated lymphoid tissue ( MALT) lymphoma is rare. There have been few reports about early primary esophageal MALT lymphoma being treated endoscopically. The clinical profile of primary esophageal MALT lymphoma is currently unclear, so it is important to accumulate more information about early esophageal MALT lymphoma. To achieve early detection of esophageal MALT lymphoma, we need more accurate knowledge and information about the macroscopic and morphological features of this tumor. Endoscopic resection is one of the most effective treatments. With respect to the lateral andvertical margins of the resected specimen, endoscopic submucosal dissection ( ESD) may be superior to endoscopic mucosal resection for treating early esophageal MALT lymphoma. Here we report the macroscopic appearance of the tumor which is the first successful case of ESD for early esophageal MALT lymphoma. [ABSTRACT FROM AUTHOR]

Aim For patients with superficial esophageal carcinoma, ESD was one of treatment modalities to remove the lesion safely and effectively. We perform this meta-analysis to determine the efficacy and incidence of complication of ESD for patients with superficial esophageal carcinoma. Method Articles were searched in MEDLINE (PubMed and Ovid), Cochrane Database of Systemic Reviews, Google scholar, and Web of Science. Two reviewers independently searched and extracted data. Meta-analysis of the efficacy of ESD was analyzed by calculating pooled en bloc and R0 resection rate. Incidence of complications such as perforation, stenosis and mediastinal emphysema was also calculated. Pooling was conducted using either fixedeffects model or random-effects model depending on the heterogeneity across studies. Results 21 studies (1152 patients and 1240 lesions) were included in this analysis. The pooled en bloc resection rate was 99% (95% CI 99%-100%). Stratified by tumor size, en bloc resection rates did not show any significant difference. The pooled R0 resection rate was 90% (95% CI 87%-93%). The pooled R0 resection rate was 85% (95% CI, 80%-90%) for large tumor and 92% (95% CI, 87%-93%) for small tumor (p < 0.001). Stenosis served as the most common reported complication with pooled incidence of 5% (95% CI 3-8%), followed by perforation (1%, 95% CI 0-1%) and mediastinal emphysema (0% CI 0-1%). The incidence of postoperative stenosis decreased significantly after 2011 (2%, 95% CI 0-3%) compared with that before 2011 (9%, 95% CI 3-8%) (p < 0.001). Conclusion ESD was an efficient modality for treating superficial esophageal carcinoma, with perfect en bloc and R0 resection rate and low complication rate. The most common complication of ESD was stenosis. Although recurrence rate was low, patients should be maintained in a scheduled surveillance program. [ABSTRACT FROM AUTHOR]

Background: Previous animal studies and a pilot clinical trial demonstrated that submucosal injection of a thiol compound called mesna could chemically soften connective tissues and thus facilitate endoscopic submucosal dissection (ESD). Objective: To evaluate whether mesna injection could reduce procedural times for gastric ESD. Design: Double-blind, block-randomized, controlled trial. Setting: University hospital. Patients: A total of 101 patients with superficial gastric cancer indicated for ESD were enrolled and randomly assigned to either the mesna or control (saline solution) group. Intervention: Traditional ESD was performed with a single bolus injection of mesna or saline solution. Main Outcome Measurements: Time for submucosal dissection (TSD). Results: En bloc resection was achieved for all lesions in the mesna group (53/53) and 51 of 52 lesions (98.08%) in the control group. TSD was not statistically different between the groups (18.62 ± 13.9 [mean ± SD] minutes for the mesna group and 24.58 ± 24.55 [mean ± SD] minutes for the control group; P = .128), and there were fewer time-consuming cases (times over 30 minutes) in the mesna group compared with controls (7/53 vs 15/52; P = .049). Multivariate regression analysis demonstrated that use of mesna, specimen size, and the presence of fibrous scars were significantly correlated with TSD (P < .05). Limitations: Single-center study. Conclusion: TSD was not significantly different between the mesna and control injection groups, but multivariate analysis indicated that mesna injection reduced procedural challenges associated with the submucosal dissection. (Clinical trial registration number: UMIN000003786.) [Copyright &y& Elsevier]

Background and Aim: A novel diagnostic algorithm for magnifying endoscopy with narrow band imaging (ME-NBI) for superficial non-ampullary duodenal epithelial tumors (SNADET) is needed because of diagnostic difficulties. Methods: In the present study, ME-NBI images taken prior to endoscopic treatment were retrospectively analyzed to investigate the relationship between ME-NBI findings and pathological findings. Lesions displaying a single surface pattern were classified as monotype, and those displaying multiple surface patterns as mixed type. Surface pattern was classified as preserved, micrified, or absent. In addition, vascular pattern was classified as absent, network, intrastructural vascular (ISV), or unclassified. Results: According to the revised Vienna classification, 100% (23/23) of mixed-type lesions were category 4/5 tumors, whereas approximately 50% (10/23) of monotype lesions were category 3 tumors. In the monotype lesions, the probability of category 4/5 tumor was 100% (2/2) in lesions with an unclassified vascular pattern, 64.3% (9/14) in lesions with an ISV pattern, 33.3% (1/3) in lesions with an absent pattern, and 25.0% (1/4) in lesions with a network pattern. Conclusion: These findings suggest the possibility of developing an effective diagnostic algorithm for ME-NBI for SNADET by determining their surface pattern and vascular pattern. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic resection (ER) is widely used as a minimally invasive therapy to remove superficial nonampullary duodenal tumor (SNADT). However, the indication criteria have not yet been clearly determined. At our institute, ER is done only for SNADT measuring ≤20 mm. We report our findings on the therapeutic outcomes of ER of SNADT. Methods: We carried out ER in 47 patients with SNADT. Indication criteria for ER included a lesion suspected as high-grade dysplasia or mucosal cancer and measuring ≤20 mm. The ER methods used to carry out en bloc resection were endoscopic mucosal resection (EMR: 17 lesions) or endoscopic submucosal dissection (ESD: 30 lesions). We then analyzed the therapeutic outcomes between them. Results: There were no significant differences between the EMR and ESD groups with regard to age, sex, location of the lesion, and histology. The most frequent gross types resected by EMR and ESD were 0-IIa and 0-IIc, respectively (P = 0.004). Median procedure time was significantly longer in ESD than in EMR, 79.5 and 9 min, respectively (P < 0.001). R0 resection was achieved in 10 cases by EMR (59%) and in 27 cases by ESD (90%) (P = 0.017). No complications occurred in cases that underwent EMR, but immediate and delayed perforations occurred in three patients who underwent ESD, although this difference was not statistically significant (P = 0.467). Conclusion: Using our indication criteria, which limited lesion size to ≤20 mm, satisfactory therapeutic outcomes of ER of SNADT were obtained. [ABSTRACT FROM AUTHOR]

Delayed perforation after duodenal endoscopic submucosal dissection (ESD) occurs at a high rate because the duodenal wall is very thin and the artificial ulcer after resection is exposed to bile and pancreatic juice. We investigated the application of the combination of a polyglycolic acid (PGA) sheet and fibrin glue. PGA sheets comprise materials widely used in surgery for absorbable thread. Fibrin glue is a heated blood product and is used for hemostasis during operations. We developed a combined method using both materials. We have used this method in two cases. One case involved an elevated lesion located in the lower duodenal angle of the duodenum. The other involved an elevated lesion in the second portion of the duodenum. About 1 week after ESD, the PGA sheets remained covering the ulcer and delayed perforation did not occur. We were able to easily carry out this method for several parts of the duodenum. This method may be helpful for the prevention of delayed perforation after duodenal ESD. [ABSTRACT FROM AUTHOR]

Background and Aim There are a number of published reports on long-term outcomes of endoscopic submucosal dissection ( ESD) for early gastric cancer ( EGC), but most reports are from single centers with median follow-up periods shorter than 5 years. This questionnaire study investigated long-term outcomes of curative ESD for EGC at six Japanese institutions with follow-up rates of at least 90% over a minimum 5-year period. Methods All consecutive patients with initial-onset EGC who underwent ESD through December 2006 at the six institutions were included in our study. The questionnaire covered pathological curability and long-term outcomes of patients with curative resections or curative resections for expanded indications over follow-up periods of at least 5 years. Results There were 3788 patients with initial-onset EGC including 1710 (45.1%) patients with curative resections and 1289 (34.0%) patients with curative resections for expanded indications. The remaining 789 (20.8%) patients had non-curativeresections. Altogether, 1601 (93.6%) patients with curative resections and 1205 (93.5%) patients with curative resections for expanded indications were successfully followed up for at least 5 years. No recurrences were reported in any of the 1601 patients with curative resections whereas three recurrences (0.2%) were reported in the 1205 patients with curative resections for expanded indications. Gastric cancer-related deaths occurred in seven (0.2%) of the 2806 patients with curative resections or curative resections for expanded indications including six patients with metachronous gastric cancer-related deaths. Conclusion This questionnaire study's results indicated favorable long-term outcomes for patients with curative resections or curative resections for expanded indications. [ABSTRACT FROM AUTHOR]

Background Perforation is a major complication of endoscopic resection for gastrointestinal neoplasms. However, little is known about delayed perforation after endoscopic resection for non-ampullary duodenal neoplasm. The aim of the present study was to investigate the clinical features of delayed perforation after endoscopic resection for non-ampullary duodenal neoplasm. Patients and Methods This was a retrospective cohort study conducted in a referral cancer center. A total of 63 patients (41 with adenomas and 22 with carcinomas) underwent endoscopic mucosal resection ( EMR) or endoscopic submucosal dissection ( ESD) from January 1993 to December 2011. Incidence, outcome, and factors associated with occurrence of delayed perforation were investigated. Results Delayed perforation occurred in four patients (6.3%). All lesions were located distal to Vater's ampulla. Three of four delayed perforations occurred within 36 h after endoscopic resection. All patients developed retroperitonitis, and two also had retroperitoneal abscesses. Although three patients were cured with conservative management, a long hospital stay was required (28-, 80-, and 81-day hospital stay, respectively). One patient required emergency surgery as a result of panperitonitis. There was, fortunately, no mortality in this series. The significant predictors of delayed perforation were location (distal to Vater's ampulla, P = 0.007) and resection method ( ESD and piecemeal EMR, P = 0.003). Conclusion Endoscopic resection for non-ampullary duodenal neoplasms has a possible risk of morbid complication i.e. delayed perforation, especially in patients with lesions located on the side distal from the ampulla and who are treated with piecemeal EMR or ESD. [ABSTRACT FROM AUTHOR]

Background The aim of the present study was to examine the safety and efficacy of endoscopic submucosal dissection ( ESD) for early gastric cancer ( EGC) based on the long-term outcomes. Patients and Methods From June 2002 to March 2007, ESD was carried out in 472 cases and 570 lesions of EGC. Post-surgical cases and status-unknown cases were excluded. The following long-term outcomes were examined in 438 patients who were reliably followed up for at least 5 years after treatment (range: 5 years [60 months] to 9 years, 9 months [117 months]): local recurrence, metachronous recurrences, and the survival rate. Results The overall en bloc resection rate was 97.7% for all lesions treated by ESD. The median procedure time was 47.0 min (range 8-345 min). The incidence of positive horizontal andvertical margins was 3.7% and 3.4%, respectively. The incidence of perforation and postoperative bleeding was 5.3% and 4.3%, respectively. There were no deaths related to ESD. Local recurrence was observed in five patients (1.1%), and metachronous recurrences in 7.8% of the patients. The post-treatment 5-year survival was 83.1%. There were no deaths as a result of gastric cancer associated with sites treated by ESD. Conclusion ESD can be considered a standard treatment for EGC based on its expanded indications and low incidences of local recurrence and lymph node metastasis. [ABSTRACT FROM AUTHOR]

Background: Endoscopic submucosal dissection (ESD) is less invasive than surgical resection, but the large mucosal defects after ESD may lead to adverse events necessitating hospitalizations. Objective: To evaluate the use of an endoscopic suturing device for closure of large mucosal defects after ESD. Design and Setting: Retrospective, single-center study. Patients: Twelve consecutive patients underwent ESD. Interventions: All lesions were removed by using a previously described ESD technique. The large mucosal defects post-ESD were completely closed with the endoscopic suturing device, and all patients were discharged home with subsequent clinical and endoscopic follow-up. Main Outcome Measurements: Bleeding and perforation rates after ESD with mucosal defect closure. Results: ESD followed by endoscopic suturing of the mucosal defects was performed in 12 patients (mean age, 64.7 ± 11.2 years, 4 lesions in the stomach, 8 lesions in the colon; mean lesion size, 42.5 ± 14.8 mm) over a period of 8 months. All lesions (100%) were removed en bloc. Closure of post-ESD defects with an endoscopic suturing device was technically feasible and fast (mean closure time, 10.0 ± 5.8 minutes per patient). Only 1 stitch (continuous suturing line) was required for complete closure in 8 patients. In the other 4 patients, the mucosal defect was closed with 2 to 4 separate stitches (mean number of sutures per patient, 1.6 ± 1.0). There were no immediate or delayed adverse events in any of the study patients. Limitations: Retrospective study. Conclusions: Closure of large post-ESD defects with the Overstitch endoscopic suturing device is technically feasible and fast and can significantly decrease treatment cost by eliminating the need for hospitalization. [Copyright &y& Elsevier]

Background and Objective: Colorectal endoscopic submucosal dissection (ESD) is technically challenging. Our aim was to identify predictors of incomplete resection and perforation in colorectal ESD. Design: Retrospective study. Setting: Academic Japanese endoscopy unit. Patients and Main Outcome Measurements: A total of 267 consecutive cases of colorectal tumors treated by ESD from May 2010 to February 2013 were analyzed. Predictors of incomplete resection and perforation, including lesion size, growth type, pathological diagnosis, use of hemostatic forceps, degree of fibrosis, history of biopsy, history of local endoscopic treatment, and endoscopic operability. Results: The incomplete resection rate was 4.1%. The perforation rate was 5.6%. Univariate analysis identified severe fibrosis (P = .032), submucosal (SM) deep (>1000 μm) invasion (P = .033) and poor endoscopic operability (P = .030) as predictors of incomplete resection, and severe fibrosis (P = .038), postendoscopic treatment (P = .016), and poor endoscopic operability (P = .012) as predictors of perforation. Multivariate analysis identified poor endoscopic operability and SM deep invasion as independent predictors of incomplete resection, and poor endoscopic operability and severe fibrosis as independent predictors of perforation. There was no adjustment of P values for multiple testing. Limitation: A single-center study by a single colonoscopist. All statistical results should be taken as descriptive only. Conclusions: Poor endoscopic operability and SM deep invasion were significant independent predictors of incomplete resections. Poor endoscopic operability and severe fibrosis were significant independent predictors of perforation. These features may provide helpful information when planning colorectal ESD. [Copyright &y& Elsevier]

Abstract: Endoscopic submucosal dissection (ESD) is a clinical therapy for early stage neoplastic lesions in the gastrointestinal tract. It is, however, faced with a crucial problem: the high occurrence of perforation. The formation of a submucosal fluid cushion (SFC) via a fluid injection is the best way to avoid perforation, and thus an appropriate biomaterial is vital for this minimally invasive endoscopic technique. In this study, we introduced an injectable thermogel as a novel submucosal injection substance in ESD. The hydrogel synthesized by us was composed of poly(lactic acid-co-glycolic acid)–poly(ethylene glycol)–poly(lactic acid-co-glycolic acid) (PLGA–PEG–PLGA) triblock copolymers. The polymer/water system was a low-viscosity fluid at room temperature and thus easily injected, and turned into a non-flowing gel at body temperature after injection. The submucosal injection of the thermogel to create SFCs was performed in both resected porcine stomachs and living minipigs. High mucosal elevation with a clear margin was maintained for a long duration. Accurate en bloc resection was achieved with the assistance of the thermogel. The mean procedure time was strikingly reduced. Meanwhile, no obvious bleeding, perforation and tissue damage were observed. The application of the thermogel not only facilitated the ESD procedure, but also increased the efficacy and safety of ESD. Therefore, the PLGA–PEG–PLGA thermogel provides an excellent submucosal injection system, and has great potential to improve the ESD technique significantly. [Copyright &y& Elsevier]

Background: Recent improvements in the survival of patients after esophagectomy have led to an increasing occurrence of gastric tube cancer (GTC). Removal of the reconstructed gastric tube, however, can lead to high morbidity and mortality. Objective: To assess the feasibility and effectiveness of endoscopic submucosal dissection (ESD) for GTC. Design: Retrospective study. Setting: National Cancer Center Hospital, Tokyo, Japan. Patients: We investigated patients with GTC after esophagectomy undergoing ESD from 1998 to 2011. Intervention: ESD. Main Outcome Measurements: Patient characteristics, endoscopic findings, technical results, histopathology including curability and Helicobacter pylori gastritis, and long-term outcomes. Results: There were 51 consecutive patients with 79 lesions including 38 lesions (48%) meeting the absolute indication, 31 (39%) satisfying the expanded indications, and 10 (13%) falling outside such indications. The median procedure time was 90 minutes. There were 73 en bloc resections (92%), 59 en bloc resections with tumor-free margins (R0 resections, 75%), and 51 curative resections (65%) based on the Japanese Gastric Cancer Association criteria. Fifty patients (98%) were assessed as H pylori gastritis positive. Adverse events included 3 perforations (3.8%) during ESD and 2 delayed perforations (2.5%) without any emergency surgery and 3 delayed bleeding (3.8%). Local recurrence was detected in 4 patients (7.8%), and metachronous GTCs were identified in 18 patients (35%). Five patients (10%) died of GTC including 3 metachronous lesions. The 5-year overall survival rate was 68.4%, and the disease-specific survival rate was 86.7% with 100% for curative and 72.7% for non-curative patients during a median follow-up period of 3.8 years (range, 0-12.1 years). Limitation: Single-center retrospective study. Conclusions: ESD for GTC was feasible and effective for curative patients; however, long-term outcomes for non-curative patients were less satisfactory. [Copyright &y& Elsevier]

Background: Endoscopic submucosal dissection (ESD) for superficial gastric neoplasm is a curative method. The aim of this study was to detect potential nonbleeding visible vessels (NBVVs) by using an infrared imaging (IRI) system. Methods: A total of 24 patients (25 lesions) were consecutively enrolled between March 2010 and December 2010. The day after ESD, endoscopist A (K.M.), who was blinded to the actual procedure of ESD, performed esophagogastroduodenoscopy (EGD) of the post-ESD ulcer base using the IRI system. Endoscopist A marked gray/blue points in the hard-copy images with the IRI system. After the first procedure, endoscopist B (Y.Y.), who was blinded to the results recorded by endoscopist A, performed a second EGD with white light endoscopy and administered water-jet pressure with the maximum level of an Olympus flushing pump onto the post-ESD ulcer base. This test can cause iatrogenic bleeding via application of pressure to NBVV in the post-ESD ulcer. Results: The IRI system detected 58 gray points and 71 blue points. The post-ESD ulcer was divided into the central area and the peripheral area. There were 14 gray points (24 %) in the central area and 44 gray points (76 %) in the peripheral area. There were 19 blue points (27 %) in the central area and 52 blue points (73 %) in the peripheral area. There was no significant difference when comparing the distribution of gray points and blue points. Bleeding occurred with a water-jet pressure in 11 of 58 gray points and in none of the blue points ( P = 0.000478). Among the gray points, bleeding in response to a water-jet pressure occurred in 2 points in the central area and in 9 points in the peripheral area. Conclusion: The IRI system detects visible vessels (VVs) that are in no need of coagulation as blue points, and VVs have a potential risk of bleeding as gray points. [ABSTRACT FROM AUTHOR]

Background: Colorectal endoscopic submucosal dissection (ESD) has made it possible to resect large specimens in an en bloc fashion. However, this can lead to postoperative adverse events, such as perforation and bleeding. Prevention of adverse events after colorectal ESD is therefore an important goal. Objective: To evaluate the utility of a shielding method using polyglycolic acid (PGA) sheets and fibrin glue to manage ulcers after colorectal ESD. Design: Prospective, single-arm, pilot study. Setting: Single tertiary care center for colorectal ESD in Japan. Patients: Ten patients with 10 colorectal tumors scheduled for ESD were enrolled between September and November 2012. Interventions: Just after ESD, we placed PGA sheets on the mucosal defect with biopsy forceps. After the whole defect was covered, we sprayed fibrin glue through a special double-lumen spraying tube. We sprayed fibrinogen through 1 lumen and then thrombin through the other lumen. Main Outcome Measurements: Success rate, mean procedure time, and adverse events associated with the covering technique and the persistence of PGA sheets at follow-up colonoscopy. Results: All 10 tumors were successfully resected. Mean tumor size was 39.7 ± 15.2 mm. All mucosal defects were successfully covered with PGA sheets. Mean procedure time was 18.7 ± 15.9 minutes. No procedure-related adverse events occurred. Upon colonoscopy 9 to 12 days after ESD, the PGA sheets were still fixed on the whole defect in 8 patients. Limitations: Small sample size. Conclusions: Our technique, which uses PGA sheets and fibrin glue, appears to shield mucosal defects, and it may be effective in reducing postoperative adverse events. [Copyright &y& Elsevier]

Background: Staging peritoneoscopy is typically done by laparoscopy in the operating room. Natural orifice transluminal endoscopic surgery peritoneoscopy is an appealing alternative to the current approach. Transcolonic submucosal endoscopy with mucosal flap (SEMF) may provide natural orifice transluminal endoscopic surgery peritoneoscopy. Objective: The aim was to verify the feasibility and safety of transcolonic peritoneoscopy with SEMF (TCPS) in a porcine survival model. Design: Survival study. Setting: Animal research unit. Intervention: Seven target beads were placed in the peritoneal cavity by laparoscopy in each of 6 animals, and TCPS was performed to identify and touch beads to simulate biopsy. Animals were euthanized after 1 week, at which time, laparotomy was performed and the SEMF site was resected for histological analysis. Main Outcome Measurements: The number of beads identified and touched during peritoneoscopy, rate of successful completion of TCPS, procedure time, mortality equivalent 1 week after TCPS, adverse event rate, histological assessment of SEMF site. Results: All 7 beads in all 6 pigs were identified and touched during TCPS. The success rate of TCP was 100%. No major adverse events occurred during the procedure. The median procedure times for the creation of a submucosal tunnel, peritoneoscopy, closure of mucosal incision, and entire procedure were 19.5, 17, 9.5, and 45 minutes, respectively. All pigs survived until euthanasia, and there was no evidence of peritonitis or severe infection. Limitations: Animal study, single endoscopist, small sample size. Conclusion: Results of this study indicate that TCPS is feasible and safe in a porcine survival model. [Copyright &y& Elsevier]

Background: Despite advances in endoscopic treatment, many colonic adenomas are still referred for surgical resection. There is a paucity of data on the suitability of these lesions for endoscopic treatment. Objective: To analyze the results of routine repeat colonoscopy in patients referred for surgical resection of colon polyps without biopsy-proven cancer. Design: Retrospective review. Setting: University hospital. Patients: Patients referred to a colorectal surgeon for surgical resection of a polyp without biopsy-proven cancer. Interventions: Repeat colonoscopy. Main Outcome Measurements: The rate of successful endoscopic treatment. Results: There were 38 lesions in 36 patients; 71% of the lesions were noncancerous and were successfully treated endoscopically. In 26% of the lesions, previous removal was attempted by the referring physician but was unsuccessful. The adenoma recurrence rate was 50%, but all recurrences were treated endoscopically and none were cancerous. Two patients were admitted for overnight observation. There were no major adverse events. Limitations: Single center, retrospective. Conclusions: In the absence of biopsy-proven invasive cancer, it is appropriate to reevaluate patients referred for surgical resection by repeat colonoscopy at an expert center. [Copyright &y& Elsevier]

Background: We previously reported that magnifying narrow-band imaging (M-NBI) is a high-performance diagnostic tool for small, depressed gastric cancer. However, an efficient diagnostic strategy using endoscopic findings has not been fully elucidated. Objective: To identify the endoscopic findings that contribute to accurate diagnosis of small, depressed gastric cancer and to propose the ideal diagnostic approach to such lesions. Design: Post-hoc analysis of a prospective, randomized, controlled trial. Setting: Nine hospitals. Patients: Three hundred fifty-three patients with small, depressed gastric lesions. Interventions: In the M-NBI group (n = 177), cancer diagnosis was made with diagnostic criteria including a demarcation line (DL) and an irregular microvascular pattern (IMVP). In the conventional white-light imaging (C-WLI) group (n = 176), diagnostic criteria were both an irregular margin and a spiny depressed area. In the C-WLI group, M-NBI was performed after C-WLI diagnosis. Main Outcome Measurements: The diagnostic performance of each criterion in M-NBI alone, C-WLI, and M-NBI after C-WLI was investigated. Results: M-NBI after C-WLI ultimately showed the best diagnostic performance in each diagnostic criterion. In M-NBI after C-WLI, evaluation of DL is technically easier than that of IMVP, and DL alone had a high sensitivity (95%) and negative predictive value (99%). The IMVP in M-NBI after C-WLI had a high sensitivity and specificity (95% and 96%, respectively) for diagnosis of cancer. Limitations: Lesions were limited to the small, depressed type. Conclusions: For a diagnosis using M-NBI after C-WLI, identification of DL is the first step, and subsequent inspection of IMVP diagnosed by DL is an efficient strategy. [Copyright &y& Elsevier]

Gastrointestinal cancers are among the commonest cancers worldwide. Treatment of these cancers at an early stage will result in a significantly better prognosis. Endoscopic submucosal dissection (ESD) is a new method of endoscopic resection that can achieve higher rates of en bloc resection for early gastrointestinal neoplasia. Three retrospective case-control studies showed that ESD achieved significantly higher en bloc resection with lower recurrence rates than endoscopic mucosal resection for treatment of early gastric cancers. Most of the reports on clinical outcomes of ESD were from countries with a high incidence of gastric cancers, including Japan and Korea. The development of ESD has been slow for countries outside Japan and Korea because ESD requires a high level of endoscopic skills, and the dissection was performed single-handedly without assistance. A newly developed robotic endoscopic platform will enhance the performance of ESD through the use of 2 robotic arms: one arm for retraction of the mucosa and the other arm for dissection. [Copyright &y& Elsevier]

Background: We developed a technique, submucosal endoscopy with mucosal resection (SEMR) intended to make endoscopic submucosal dissection easier and safer. With this technique, the submucosal layer is balloon dissected in lieu of electrosurgical knife dissection. The aim of this study was to further evaluate SEMR in the porcine rectum and colon. Methods: Targeted sites in the rectum and the distal colon were marked by spot coagulation. Submucosal fluid cushions (SFC) were created followed by a circumferential mucosal incision. After isolation of the targeted mucosa, balloon dissection was initiated. The balloon catheter was inserted deep into SFC and the inflated balloon repeatedly pulled back toward the endoscope tip to disrupt the submucosa. Residual strands of submucosa were cut. Dissection difficulty scores (DDS) were used using a visual analogue scale ranging from 0 to 5 (failed). The entire study period was divided into three periods (first period, pigs 1–10; second period, pigs 11–20; third period, pigs 21–30). Results: Sixty lesions in 30 pigs were resected using SEMR. The en block resection rate was 95 %. There were three incomplete resections, two as a result of an errant site location and one as a result of a floppy prototype balloon catheter tip. The median resected size, procedure time, and DDS were 6.0 cm, 25 min, and 1. All three failed cases occurred in first period. The procedure time in third period was significantly shorter than the second period ( P = 0.0017). The DDS in first period was significantly higher than the second ( P = 0.0024) and third ( P = 0.0155) periods. Two perforations, one muscularis propria catheter perforation, and one mucosal perforation were observed (3.3 %). Conclusions: Large mucosal target sites in the rectum and distal colon could be safely removed en bloc by means of a hybrid technique, SEMR, with blunt submucosal balloon dissection. [ABSTRACT FROM AUTHOR]

Background: Among all types of superficial gastrointestinal (GI) neoplasms, colorectal lesions are recognized as one of the most difficult locations to operate, due to the limited operation space, physiological bends, poor visualization of the submucosal dissection plane sheltered by colorectal crinkle wall, and the thin intestinal mucosa layer which is easy to perforation. The purpose of this prospective study is to evaluate the feasibility, efficacy, and safety of a novel endoscopic traction technique in assisting the endoscopic submucosal dissection (ESD) procedure in colorectal lesions., Method: A total of 117 patients with colonic lesions who underwent endoscopic treatment were enrolled between August 2020 and January 2021 at the endoscopic center of Beijing Chao-yang Hospital of Capital Medical University. Based on whether traction device was used during the operation, 60 and 57 patients were assigned to the conventional ESD group and clips and rubber band triangle traction-assisted ESD group (CRT-ESD, in which three clips and a rubber band were used to form an elastic triangular traction device), respectively. The total procedure time (TPT), submucosal dissection time (SDT), submucosal dissection speed (SDS), and rate of adverse events of the two groups were analyzed., Results: After excluding patients who did not undergo treatment (conventional ESD, 1; CRT-ESD, 4), 112 patients were included in the study (conventional ESD, 59; CRT-ESD, 53). The baseline characteristics of the patients were well balanced between the two groups. The TPT (58.71 ± 26.22 min vs 33.58 ± 9.88 min, p < 0.001) and SDT (49.24 ± 23.75 min vs 26.34 ± 8.75 min, p < 0.001) were significantly different between the conventional ESD group and CRT-ESD group. The CRT-ESD group had significantly higher SDS than that of the traditional ESD group (0.54 ± 0.42 cm 2 /min vs 0.89 ± 0.40 cm 2 /min, p < 0.001). There were 4 (6.8%) cases of perforation in the traditional ESD group, and no perforation occurred in traction-assisted ESD., Conclusions: Compared with traditional ESD, CRT-ESD with clip and rubber band is both safer and more effective in the treatment of colorectal lesions., (© 2022. The Author(s).)

Background: Psychological problems may promote peptic ulcers. Ulcer-like wounds can be formed after gastric endoscopic submucosal dissection (ESD). The influence of family support on the healing of gastric ESD-induced ulcers remains largely undetermined., Objective: In the present study, we aimed to assess the Hospital Anxiety and Depression Scale (HADS) scores and the incidence of post-ESD complications in patients with family support in the care process and those in the non-relative group., Materials and Methods: A total of 191 patients aged between 30 and 70 years who received gastric ESD were evaluated with the Chinese version of HADS. Differences in depression and anxiety between the two groups were compared using the chi-square test and t -test. Multivariable logistic regression models were used to examine whether anxiety and depression were the risk factors for post-ESD complications., Results: The mean values of HADS-A (4.61 ± 2.89 vs. 5.56 ± 3.07, p = 0.042) and HADS-D (4.14 ± 3.03 vs. 4.97 ± 2.61, p = 0.048) scores were significantly lower in patients with accompanying relatives compared with those in the non-relative group. Besides, through the pre-ESD and post-ESD self-contrast, the scores of anxiety and depression in the relative-group were 0.57 and 0.56, respectively ( p < 0.001), while those in the non-relative group were increased by 1.43 and 1.49, respectively ( p < 0.001). Multivariable logistic regression analysis revealed that HADS-A, HADS-D scores, and age were significantly correlated with post-ESD abdominal pain ( P < 0.05)., Conclusions: The occurrence and degree of adverse emotions such as psychological anxiety and depression in patients who received gastric ESD with accompanying relatives during hospitalization may were reduced, and the incidence of gastric post-ESD abdominal pain may was also decreased., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Gao, Gan, Huang, Liu, Wu, Wang, Li and Yao.)

Endoscopic submucosal dissection (ESD) and endoscopic submucosal resection (EMR) are non-invasive endoscopic techniques. They allow an early excised gastrointestinal (GI) mucosal precancerous lessions. For their application is necessary to use a submucosal injection that lifts the area to excise. The main objective of this study was the preparation of a microparticulate-based fluid for injection in the GI submucosa. Alginate microparticles (MPs) were developed by the solvent displacement technique and characterized by particle size, surface electrical properties, swelling, degradation, rheology, adhesion, leakage, syringeablity and stability. Furthermore, their potential to form a submucosal cushion was assayed in porcine stomach mucosa and porcine colon mucosa. Results showed MPs sizes below 160 μm, negative surface charge around -50 mV at pH = 6, high rates of swelling and good adhesion. The microparticulate-based fluid exhibited pseudoplastic behavior following the Ostwald-de Waele rheological model. A brief force is sufficient for its injection through a syringe. Finally, formulations were able to provide a submucosa elevation of 1.70 cm for more than 90 min and 120 min in the porcine stomach and colon, respectively., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Colonic endoscopic submucosal dissection (ESD) is challenging as a result of the limited ability of conventional endoscopic instruments to achieve traction and exposure. The aim of this study was to evaluate the feasibility of colonic ESD in a porcine model using a novel endoscopic surgical platform, the Anubiscope (Karl Storz, Tüttlingen, Germany), equipped with two working channels for surgical instruments with four degrees of freedom offering surgical triangulation. Methods: Nine ESDs were performed by a surgeon without any ESD experience in three swine, at 25, 15, and 10 cm above the anal verge with the Anubiscope. Sixteen ESDs were performed by an experienced endoscopist in five swine using conventional endoscopic instruments. Major ESD steps included the following for both groups: scoring the area, submucosal injection of glycerol, precut, and submucosal dissection. Outcomes measured were as follows: dissection time and speed, specimen size, en bloc dissection, and complications. Results: No perforations occurred in the Anubis group, while there were eight perforations (50 %) in the conventional group ( p = 0.02). Complete and en bloc dissections were achieved in all cases in the Anubis group. Mean dissection time for completed cases was statistically significantly shorter in the Anubis group (32.3 ± 16.1 vs. 55.87 ± 7.66 min; p = 0.0019). Mean specimen size was higher in the conventional group (1321 ± 230 vs. 927.77 ± 229.96 mm; p = 0.003), but mean dissection speed was similar (35.95 ± 18.93 vs. 23.98 ± 5.02 mm/min in the Anubis and conventional groups, respectively; p = 0.1). Conclusions: Colonic ESDs were feasible in pig models with the Anubiscope. This surgical endoscopic platform is promising for endoluminal surgical procedures such as ESD, as it is user-friendly, effective, and safe. [ABSTRACT FROM AUTHOR]

Background In recent years, endoscopic submucosal dissection ( ESD) has often been used for the treatment of laterally spreading tumors ( LST) of the rectum. The present study was carried out with the aim of clarifying the characteristics of each of the subtypes of LST in the rectum that are often treated by ESD. Patients and Methods This study involved 141 rectal LST that were initially treated at our hospital between March 2005 and December 2010 and whose endoscopic images and histopathological specimens could be re-examined. The LST were divided into LST- G- H (homogeneous type), LST- G- MIX (nodular mixed type), LST-NG- F (flat type) and LST-NG- PD (pseudo-depressed type) type lesions, and tumor diameter and depth of invasion of each of these tumor types were investigated. Results Regarding the depth of invasion, the proportion of submucosa-massive ( SM-m) lesions was high in the LST-NG- PDtumors, even among tumors measuring <20 mm in diameter; both the rate of cancer and proportion of SM-m lesions were significantly higher in the LST-NG- PD tumors than in the LST-NG- F tumors ( P < 0.05). In both LST-NG- MIX and LST-NG- PD tumors, the proportion of SM-m lesions was significantly higher in the lower rectum than in the upper rectum ( P < 0.05). Conclusion For LST of the rectum (particularly of the lower rectum), it is necessary to carefully select the treatment considering LST subclass and tumor diameter from the standpoint of the presence of malignancy, quality of life, and prognosis of patients. [ABSTRACT FROM AUTHOR]

Background Certain tumor characteristics may pose challenges when endoscopically determining the horizontal extent of early gastric cancers ( EGC). In the present study, clinicopathological features related to inaccurate endoscopic evaluation of horizontal extent of intestinal-type EGC were analyzed. Patients and Methods We analyzed 431 lesions with intestinal-type EGC treated by endoscopic submucosal dissection ( ESD) at our hospital. We focused on whether pretreatment demarcation was accurate by comparing positional relationships between marking dots and tumor edges in resected specimens, and factors related to inaccurate evaluation were analyzed. Gender, age, tumor size, location, circumference, depth, ulceration, macroscopic type, presence of a flat (0- IIb) component, predominant histological type, mixture of diffuse-type adenocarcinoma, mixed histology, and use of magnification endoscopy with narrow band imaging were analyzed. Reasons for inaccurate evaluation were also investigated by re-examining endoscopic images and prepared histological slides. Results Rate of inaccurate evaluation of horizontal extent was 7.4% (32/431 lesions). Multivariate analysis revealed the following significant independent variables contributing to inaccurate endoscopic evaluation: presence of a flat component, large size, and predominant histological findings of moderately differentiated adenocarcinoma. Re-examination of prepared histological slides of inaccurately evaluated cases revealed a marginal flat spreading area in 28 of the 32 lesions (87.5%). In 14 of the 32 lesions (43.8%), tumor margins were composed of moderately differentiated adenocarcinoma. Conclusions For lesions with a flat component, large lesions, and moderately differentiated adenocarcinoma, determination of the horizontal extent can be challenging in EGC indicated for ESD, even with the best available endoscopic tools. [ABSTRACT FROM AUTHOR]

Background: A prototype endoscope was designed to improve visualization and dissection of tissue with the use of 2 working channels with different deflections. Objective: To evaluate the efficacy and operability of a prototype endoscope in comparison with a conventional double-channel endoscope for rectal endoscopic submucosal dissection (ESD). Design: Randomized, prospective, controlled, ex vivo study. Setting: Academic medical center. Methods: A total of 80 standardized artificial lesions measuring 3 × 3 cm were created approximately 5 cm from the anal verge in fresh ex vivo porcine colorectal specimens. Two endoscopists each completed 20 cases with the prototype endoscope and 20 cases with the conventional endoscope. Main Outcome Measurements: An independent observer recorded procedure time, specimen size, en bloc resection, and perforation rate. Results: For the ESD novice, the mean submucosal dissection time (10.5 ± 3.8 vs 14.9 ± 7.3 minutes; P = .024) and total procedure time (18.1 ± 5.2 vs 23.6 ± 8.2 minutes; P = .015) were significantly shorter in the prototype group in comparison with the conventional group. For the ESD expert, there was no significant difference between the mean circumferential resection, submucosal dissection, and total procedure time (prototype group 14.2 ± 6.0 minutes, conventional group 14.2 ± 8.8 minutes; P = .992). The overall perforation and en bloc resection rates were not significantly different between groups. Limitations: Ex vivo study. Conclusion: In this ex vivo prospective comparison study, there was a technical advantage for the ESD novice with the prototype endoscope that resulted in a shorter procedure time, which was not observed for cases performed by the ESD expert. [Copyright &y& Elsevier]

Background: Most previous studies of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms were retrospective; prospective studies are scant. Objective: To prospectively assess the efficacy and safety of ESD for superficial esophageal neoplasms. Design: Phase II study. Setting: University hospital. Patients: Fifty-two patients (median age 68 years; 48 men) who had a histologic diagnosis of superficial esophageal cancer without metastasis on CT or high-grade intraepithelial neoplasia (HGIN) were enrolled from April 2009 through November 2011. Intervention: ESD was used to treat 56 lesions. All procedures were done by 4 endoscopists who each had previously performed ESD in more than 100 patients with gastric tumors. Main Outcome Measurements: The primary endpoint was the R0 resection rate, and secondary endpoints were the safety and the rate of accurately diagnosing tumor depth on endoscopic examination. Results: The median treatment time was 69 minutes (24-168 minutes). The histopathologic diagnosis was squamous cell carcinoma in 49 lesions, HGIN in 5, and tubular adenocarcinoma in 2. The en bloc resection rate and R0 resection rate were 100% and 94.6%, respectively. The rates of adverse events during ESD and after ESD were 22.2% and 53.8%, respectively, but most events were mild. One patient (1.9%) had mediastinal emphysema without perforation. The rate of accurately diagnosing tumor depth on endoscopic examination was 76.8%. Limitations: Single-center, nonrandomized study. Conclusion: Our study showed that ESD was an effective and relatively safe treatment for superficial esophageal neoplasms. ESD may be a useful treatment option for superficial esophageal neoplasms in hospitals with endoscopists who are experts in performing ESD for gastric tumors. (Clinical trial registration number: UMIN000002047.) [Copyright &y& Elsevier]

Background: Zenker's diverticulum (ZD) is a rare disorder but is associated with significant morbidity. Cricopharyngeal (CP) myotomy is the mainstay of treatment, and various flexible endoscopic techniques have been used for division of the septum. However, there is a constant need for improvement in accessories. Objective: To evaluate the safety and effectiveness of a new electrocautery endoscopic scissor for CP myotomy in patients with symptomatic ZD. Design: Observational human study. Setting: Tertiary-care hospital. Patients: This study involved 3 patients with symptomatic ZD. Intervention: Flexible endoscopic CP myotomy was performed by using a novel scissors-type grasping device. CP myotomy involved 4 steps: (1) opening of the forceps, (2) grasping the muscle fiber, (3) closure of the forceps with application of gentle traction, and (4) dissection of muscle fibers by using cutting current. Intraprocedural bleeding was controlled with the same instrument by grasping vessels and applying coagulation current. Main Outcome Measurements: Overall feasibility and performance, procedure time to achieve complete CP myotomy. Results: CP myotomy was successfully performed in all patients. Mean procedure time was 10.6 minutes. There were no major adverse events. Minor intraprocedure bleeding occurred in 1 patient. Limitations: Single arm, limited number of patients. Conclusion: The new instrument has potential advantages in comparison with standard instruments used for CP myotomy. The advantages of this new technique are better control of cutting and hemostatic abilities. [Copyright &y& Elsevier]