• Clinical Endoscopy
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• v.56 no.1
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• pp.55-64
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• 2023

Background/Aims: Endoscopic submucosal dissection (ESD) has been established as a treatment modality for superficial esophageal squamous cell carcinoma (ESCC). Long-term follow-up data are lacking in Western countries. The aim of this study was to analyze long-term survival in a Western center. Methods: Patients undergoing ESD for ESCC were included. The analysis was performed retrospectively using a prospectively collected database. Results: R0 resection rate was 96.7% (59/61 lesions in 58 patients). Twenty-seven patients (46.6%) fulfilled the curative resection criteria (M1/M2) (group A), 11 patients (19.0%) had M3 lesions without lymphovascular invasion (LVI) (group B), and 20 patients (34.5%) had lesions with submucosal invasion or LVI (group C). Additional treatment was recommended after non-curative resection. It was not performed in 20/31 patients (64.5%), mainly because of comorbidities (75%). Twenty-nine out of 58 (50.0%) patients died during a mean follow-up of 3.7 years. Death was related to ESCC in 17.2% (5/29) of patients. The disease-specific survival rate after curative resection was 100%. Overall survival rates after 5 years were 61.5%, 63.6% and 28.1% for groups A, B, and C, respectively. The overall survival was significantly worse after non-curative resection (p=0.038). Conclusions: Non-curative resection is frequent after ESD for ESCC in Western patients. The long-term prognosis is limited and mainly determined by comorbidity. Early diagnosis and pre-interventional assessments need to be improved.

• Clinical Endoscopy
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• v.56 no.4
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• pp.423-432
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• 2023

Compared to endoscopic mucosal resection (EMR), colonoscopic endoscopic submucosal dissection (C-ESD) has the advantages of higher en bloc resection rates and lower recurrence rates of colorectal neoplasms. Therefore, C-ESD is considered an effective treatment method for laterally spread tumors and early colorectal cancer. However, C-ESD is technically more difficult and requires a longer procedure time than EMR. In addition to therapeutic efficacy and procedural difficulty, safety concerns should always be considered when performing C-ESD in clinical practice. Bleeding and perforation are the main adverse events associated with C-ESD and can occur during C-ESD or after the completion of the procedure. Most bleeding associated with C-ESD can be managed endoscopically, even if it occurs during or after the procedure. More recently, most perforations identified during C-ESD can also be managed endoscopically, unless the mural defect is too large to be sutured with endoscopic devices or the patient is hemodynamically unstable. Delayed perforations are quite rare, but they require surgical treatment more frequently than endoscopically identified intraprocedural perforations or radiologically identified immediate postprocedural perforations. Post-ESD coagulation syndrome is a relatively underestimated adverse event, which can mimic localized peritonitis from perforation. Here, we classify and characterize the complications associated with C-ESD and recommend management options for them.

• Journal of Digestive Cancer Research
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• v.5 no.1
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• pp.44-49
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• 2017

Background: Recently, endoscopic submucosal dissection (ESD) with laparoscopic sentinel lymph node dissection, named ESN or endoscopic full-thickness gastric resection with laparoscopic sentinel lymph node dissection, named Hybrid-natural orifice transluminal endoscopic surgery (NOTES) was suggested the possibility of minimally invasive treatment for patients with early gastric cancer (EGC) who were beyond the indication of ESD. This study aimed to evaluate the outcomes of ESN or Hybrid-NOTES. Methods: We retrospectively analyzed patients treated with these therapies from January 2009 to May 2013 in terms of short- and long-term outcomes. Each patient was diagnosed with EGC but was not included in ESD indications and had the high risk of lymph node metastasis (LNM). Results: A total of 42 patients with EGC treated by ESN or Hybrid-NOTES. Of the 21 patients who underwent ESN, a total of 4 patients underwent additional gastrectomy, 1 with LNM, 1 with surgical complication, and 2 with noncurative resection. Of the 21 patients who underwent Hybrid-NOTES, a total of 5 patients underwent additional surgery, 1 with LNM, 2 with surgical complication, and 2 with noncurative resection. Overall survival was 100% over a mean follow-up of 75 months, but 3 patients underwent ESD or gastrectomy with metachronous lesion. And 1 patient who had received ESN was found to have a metastatic lymph node and undergo palliative chemotherapy. Conclusion: ESN or Hybrid-NOTES showed favorable short-and long-term outcomes. These methods may be utilized as a bridge between ESD and gastrectomy in the case of EGC which is more likely to have LNM beyond the ESD indications.

• Journal of Gastric Cancer
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• v.20 no.4
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• pp.345-354
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• 2020

Early detection of gastric cancer is crucial because the survival rate can be improved through curative treatment. Although surgery and gastrectomy with lymph node dissection remain as the gold standard for curative treatment, early gastric cancer (EGC) with negligible risk of lymph node metastasis can be treated with endoscopic resection (ER), such as endoscopic submucosal dissection. Among gastric cancers, undifferentiated-type cancer is distinguished from differentiated-type cancer in various aspects in terms of clinical features and pathophysiology. The undifferentiated-type cancer is also known to be associated with an aggressive behavior and a poor prognosis. Therefore, the indication of ER for undifferentiated EGC is limited compared with differentiated-type. Recent studies have reported that ER for undifferentiated EGC is safe and shows favorable short- and long-term outcomes. However, it is necessary to understand the details of the research results and to selectively accept them. In this review, we aimed to evaluate the current practice guidelines and the short-term and long-term outcomes of ER for undifferentiated type EGC.

• Clinical Endoscopy
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• v.57 no.3
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• pp.293-301
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• 2024

Cap-assisted endoscopy refers to a procedure in which a short tube made of a polymer (mostly transparent) is attached to the distal tip of the endoscope to enhance its diagnostic and therapeutic capabilities. It is reported to be particularly useful in: (1) minimizing blind spots during screening colonoscopy, (2) providing a constant distance from a lesion for clear visualization during magnifying endoscopy, (3) accurately assessing the size of various gastrointestinal lesions, (4) preventing mucosal injury during foreign body removal, (5) securing adequate workspace in the submucosal space during endoscopic submucosal dissection or third space endoscopy, (6) providing an optimal approach angle to a target, and (7) suctioning mucosal and submucosal tissue with negative pressure for resection or approximation. Here, we review various applications of attachable caps in diagnostic and therapeutic endoscopy and their future implications.

• Journal of Gastric Cancer
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• v.19 no.2
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• pp.157-164
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• 2019

Purpose: Although standard radical gastrectomy is recommended after noncurative resection of endoscopic submucosal dissection (ESD) for early gastric cancer in most cases, residual tumor and lymph node metastasis have not been identified after surgery. The aim of this study is to evaluate the feasibility of sentinel node navigation surgery after noncurative ESD. Materials and Methods: This trial is an investigator-initiated, multicenter prospective phase II trial. Patients who underwent ESD for clinical stage T1N0M0 gastric cancer with noncurative resections were eligible. Qualified investigators who completed the prior phase III trial (SENORITA 1) are exclusively allowed to participate. In this study, 2 detection methods will be used: 1) intraoperative endoscopic submucosal injection of dual tracer, including radioisotope and indocyanine green (ICG) with sentinel basins detected using gamma-probe; 2) endoscopic injection of ICG, with sentinel basins detected using a fluorescence imaging system. Standard laparoscopic gastrectomy with lymphadenectomy will be performed. Sample size is calculated based on the inferior confidence interval of the detection rate of 95%, and the calculated accrual is 237 patients. The primary endpoint is detection rate, and the secondary endpoints are sensitivity and postoperative complications. Conclusions: This study is expected to clarify the feasibility of laparoscopic sentinel basin dissection after noncurative ESD. If the feasibility is demonstrated, a multicenter phase III trial will be initiated to compare laparoscopic sentinel node navigation surgery versus laparoscopic standard gastrectomy in early gastric cancer after endoscopic resection.

• Journal of Digestive Cancer Research
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• v.11 no.3
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• pp.125-129
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• 2023

Appropriate sedation and analgesia are crucial for successful endoscopic procedures, patient safety, and satisfaction. Endoscopic resection for upper gastrointestinal tumors requires a deep sedation level because the procedure is lengthy and induces moderate to severe pain. Continuous patient consciousness assessment and vigilant vital signs monitoring are required for deep sedation. General anesthesia may unintentionally occur even during deep sedation for endoscopic tumor resection, which may cause unexpected complications, especially in high-risk patients. Previous studies have revealed that general anesthesia increases the en bloc resection rate and decreases the procedure time. Complications, such as perforation, aspiration pneumonia, and cardiopulmonary instability, including hypoxemia, hypotension, and arrhythmia, occurred more frequently in patients with sedation compared to those with general anesthesia. Therefore, general anesthesia demonstrated potential benefits in endoscopic treatment results and patient safety. General anesthesia should be considered a useful alternative for sedation in patients undergoing endoscopic gastrointestinal tumor resection. However, more high-quality prospective studies are required to determine the safety and effectiveness of general anesthesia in endoscopic upper gastrointestinal tumor resection because most studies comparing general anesthesia and sedation in these procedures have been retrospectively conducted and the results were inconsistent.

• Clinical Endoscopy
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• v.57 no.3
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• pp.317-328
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• 2024

Background/Aims: In this meta-analysis, we studied the safety and efficacy of endoscopic submucosal dissection (ESD) for colorectal dysplasia in patients with inflammatory bowel disease (IBD). Methods: Multiple databases were searched, and studies were retrieved based on pre-specified criteria until October 2022. The outcomes assessed were resection rates, procedural complications, local recurrence, metachronous tumors, and the need for surgery after ESD in IBD. Standard meta-analysis methods were followed using the random-effects model, and I²% was used to assess heterogeneity. Results: Twelve studies comprising 291 dysplastic lesions in 274 patients were included with a median follow-up of 25 months. The pooled en-bloc resection, R0 resection, and curative resection rates were 92.5% (95% confidence interval [CI], 87.9%-95.4%; I²=0%), 81.5% (95% CI, 72.5%-88%; I²=43%), and 48.9% (95% CI, 32.1%-65.9%; I²=87%), respectively. The local recurrence rate was 3.9% (95% CI, 2%-7.5%; I²=0%). The pooled rates of bleeding and perforation were 7.7% (95% CI, 4.5%-13%; I²=10%) and 5.3% (95% CI, 3.1%-8.9%; I²=0%), respectively. The rates of metachronous recurrence and additional surgery following ESD were 10% (95% CI, 5.2%-18.2%; I²=55%) and 13% (95% CI, 8.5%-19.3%; I²=54%), respectively. Conclusions: ESD is safe and effective for the resection of dysplastic lesions in IBD with an excellent pooled rate of en-bloc and R0 resection.

• Journal of Digestive Cancer Research
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• v.7 no.2
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• pp.57-60
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• 2019

Definitive chemoradiotherapy (CRT) with its significant efficacy and safety in esophageal cancer is reserved for patients with unresectable tumor or those who decline surgery. However, the incidence of locoregional failure or recurrence after definitive CRT remains high. Although esophagectomy is the standard treatment for locoregional failure or recurrence, this approach is associated with high mortality and morbidity. A 56-year-old man diagnosed with esophageal squamous cell carcinoma who refused to undergo surgery received definitive CRT. An endoscopy for response assessment performed after 2 months revealed a residual lesion, which was completely resected by salvage endoscopic submucosal dissection. To the best of our knowledge, endoscopic resection in locoregional failure or recurrence after definitive CRT is very rarely reported, and there are no guidelines or consensus to date. Here, we report a case of successful salvage endoscopic resection of residual lesion after definitive CRT.

• Journal of Gastric Cancer
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• v.15 no.2
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• pp.139-142
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• 2015

Hepatic metastasis of early gastric cancer (EGC) following subtotal gastrectomy with lymphadenectomy is rare. We report the case of a 61-year-old male patient who was diagnosed with EGC that was initially treated using endoscopic submucosal dissection (ESD) and subsequently underwent laparoscopic subtotal gastrectomy. Histopathological examination of the patient's ESD specimen showed a moderately differentiated tubular adenocarcinoma invading the submucosa without lymphatic invasion. The deep margin of the specimen was positive for adenocarcinoma, and he subsequently underwent laparoscopic distal gastrectomy. The patient developed liver metastasis 15 months after the operation and then underwent liver resection. Histology of the resected specimen confirmed the diagnosis of two foci of metastatic adenocarcinoma originating from stomach cancer. Immunohistochemical analysis of the specimen demonstrated overexpression of human epidermal growth factor receptor 2. The patient was treated with trastuzumab in combination with chemotherapy consisting of capecitabine and cisplatin. Twenty-four months after the operation, the patient remained free of recurrence.