Background and Aims Although endoscopic submucosal dissection (ESD) is a significant advancement in therapeutic endoscopy, it is a complicated technique and requires considerable expertise. In this ...exploratory study, we evaluated the efficacy of a simple traction method that uses dental floss and a hemoclip (DFC) and was developed to overcome the technical difficulties of ESD. Methods In total, 238 early gastric cancers treated by ESD between May 2012 and December 2014 at Tokyo Medical University were retrospectively reviewed. Lesions treated by conventional ESD (n = 185) and by ESD with DFC (ESD-DFC) (n = 53) were compared. Multivariable analyses and propensity score matching were used to compensate for the differences in age, sex, resected specimen size, lesion location, lesion position, presence of ulceration, and operator level. The procedure time, rate of en bloc and complete resection, and rates of adverse events were evaluated between the 2 groups. Results Propensity score matching analysis created 43 matched pairs. Adjusted comparisons between ESD-DFC and conventional ESD showed similar treatment outcomes (en bloc resection rate: 97.7% vs 100%, P = .315; complete resection rate: 90.7% vs 95.3%, P = .397; perforation during ESD rate: 2.3% vs 2.3%, P = 1.000; post-ESD bleeding rate: 4.7% vs 4.7%, P = 1.000) but a significantly shorter procedure time for ESD-DFC (82.2 ± 79.5 minutes vs 118.2 ± 71.6 minutes, P = .002). Conclusion ESD-DFC facilitated rapid ESD with good visualization and traction while ensuring high curability and safety.
Summary Gastric cancer is the second most common cause of death from cancer in Asia. Although surgery is the standard treatment for this disease, early detection and treatment is the only way to ...reduce mortality. This Review summarises the epidemiology of gastric cancer, and the evidence for, and current practices of, screening in Asia. Few Asian countries have implemented a national screening programme for gastric cancer; most have adopted opportunistic screening of high-risk individuals only. Although screening by endoscopy seems to be the most accurate method for detection of gastric cancer, the availability of endoscopic instruments and expertise for mass screening remains questionable—even in developed countries such as Japan. Therefore, barium studies or serum-pepsinogen testing are sometimes used as the initial screening tool in some countries, and patients with abnormal results are screened by endoscopy. Despite the strong link between infection with Helicobacter pylori and gastric cancer, more data are needed to define the role of its eradication in the prevention of gastric cancer in Asia. At present, there is a paucity of quality data from Asia to lend support for screening for gastric cancer.
Background and Aims Balloon enteroscopy–assisted ERCP has provided a marked improvement in the success rate of reaching the papilla and consecutive ERCP procedures in patients with surgically altered ...anatomy in the Roux-en-Y reconstruction setting. However, limited data are available on the outcome of balloon enteroscopy–assisted ERCP in patients with Roux-en-Y anatomy who have naïve papillae. We retrospectively evaluated the feasibility of balloon enteroscopy–assisted ERCP in Roux-en-Y reconstruction after total or subtotal gastrectomy (RYG) with native papillae. Methods We performed 123 ERCP procedures in 109 patients with RYG. Among these patients, 90 consecutive ERCPs in 90 patients with native papillae were included. When selective biliary cannulation failed, the double-guidewire technique, the precut technique, or the rendezvous technique were performed as advanced cannulation methods. Results The overall success rate of reaching the papilla was 93.5% (115/123). The total procedure success rate was 88.1% (96/109). The adverse event rate was 7.3% (8/109). The success rate of the standard cannulation of the intact papilla was 67.8% (61/90). The final cannulation success rate was 95.6% (86/90) by using advanced cannulation methods. Conclusions Standard cannulation of the intact papilla in RYG cases remains challenging and uncertain. The use of various advanced cannulation methods improves the deep cannulation rate. Once selective cannulation succeeds, the treatment success rate is very high.
Background Surgical gastrojejunostomy is associated with relatively high morbidity and mortality rates. However, current experimental EUS-guided gastrojejunostomy information is limited. Objective To ...evaluate a novel EUS-guided gastrojejunostomy technique using a new enteric balloon and lumen-apposing metal stent. Design Animal experiment. Setting Animal laboratory at a referral center. Subjects and Interventions In 5 pigs, gastrojejunostomies were created under EUS guidance. Fully covered lumen-apposing stents were placed between the stomach and the jejunum. Main Outcome Measurements Technical success and adverse events of EUS-guided gastrojejunostomy. Results All stents, with 1 exception, were successfully deployed without any adverse events. The mean time to stent placement was 44.2 minutes (range 28-64 minutes). All animals showed normal eating behavior without signs of infection for 1 month after the procedure. Endoscopic imaging of the stomach site showed the stent to be patent and stable, without dislodgment, in all of the pigs. Necropsy showed complete adhesion between the stomach and the jejunum wall. Limitations Pilot study. Conclusions Creation of an EUS-guided gastrojejunostomy by using a novel enteric balloon and metal stent appears to be promising as a minimally invasive treatment.
Background The treatment of early gastric cancer (EGC) by endoscopic submucosal dissection (ESD) has been rapidly gaining popularity in Japan. However, the procedure needs a high quality of skill. To ...facilitate complicated ESD by using a single working-channel gastroscope (“one-hand surgery method”), the magnetic-anchor-guided ESD (MAG-ESD) controlled by an extracorporeal electromagnet was reported to be successful in a porcine model. Objectives The purpose of this prospective clinical trial was to evaluate the feasibility of MAG-ESD for large EGC located on the gastric body in human beings. Design Prospective clinical trial at a single center. Setting National Cancer Center Hospital, Tokyo, Japan. Subjects From January 2005 to May 2006, 25 patients with EGC >20 mm in diameter, located in the gastric body, and intestinal-type histology were enrolled. Patients with a cardiac pacemaker, advanced malignancy in other organs, severe cardiac and/or pulmonary diseases, and uncontrolled hypertension and/or diabetes mellitus were excluded from this study. Interventions Similar to a standard ESD, the MAG-ESD procedure was performed with the patient under conscious sedation by intravenous injection of midazolam (3–5 mg) and pentazocine (15 mg). Main Outcome Measurements Unfavorable events and other intraoperative complications caused by the magnetic anchor or the magnetic force were recorded and evaluated. Two GI endoscopists (T.G., I.O.) assessed whether the magnetic anchor facilitated gastric ESD according to 2 criteria: “supportive” and “not supportive.” The en bloc resection rate, complications, total operation time, bleeding, perforation, and recurrence rate were also evaluated. The total operation time was measured from insertion to withdrawal of the endoscope, including the retrieving of the magnetic anchor or anchors. Results All tumors were resected en bloc, without any perforations or severe uncontrollable bleeding. All magnetic anchors were safely retrieved. Two endoscopists assessed that the MAG system was supportive in 23 patients. None of the patients experienced physiologic and mental abnormalities as a result of long-term magnetic-field exposure. During a median follow-up of 20 months (15–32 months), neither delayed adverse effects nor allergies caused by the stainless steel of the magnetic anchor were observed. Conclusions MAG-ESD is a feasible and safe method that allowed an excellent visualization by suitable tissue tension and facilitated gastric ESD in patients with EGC. The system should be miniaturized to make it applicable in daily clinical practice.
Background Endoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed. Objective To evaluate a ...stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol. Design Prospective study in the Western setting. Setting This study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD. Patients Indications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis. Intervention Training consisted of 5 unsupervised ESDs on isolated stomach, an observation period at an ESD expert Japanese center, 1 supervised ESD on isolated stomach, and retraining on 1 rectal ESD under supervision. The operative training on patients was performed without supervision moving from the rectum to the colon according to the competence achieved. Main Outcome Measurements Competence was defined as an 80% en bloc resection rate plus a statistically significant reduction in operating time per square centimeter. Learning curves were calculated based on consecutive blocks of 5 procedures. Results From February 2009 to February 2012, 30 rectal and 30 colonic ESDs were performed. The rectal ESD learning curve showed that the en bloc resection rate was 80% after 5 procedures ( P = not significant); the operating time per square centimeter significantly decreased after 20 procedures ( P = .0079); perforation occurred in 1 patient. The colonic ESD learning curve showed that the en bloc resection rate was 80% after 20 procedures ( P = not significant); the operating time per square centimeter significantly decreased after 20 procedures ( P = .031); perforations occurred in 2 patients. Limitations Single-center design. Conclusions A minimal intensive training seems sufficient for endoscopists expert in therapeutic procedures to take up ESD in a not overly arduous incremental method with separate and sequential learning curves for the rectum and colon.
Background Narrow-band imaging (NBI) makes it possible to emphasize the imaging of certain features, such as mucosal structures and mucosal microvessels in GI-tract diseases. Recently, video peroral ...cholangioscopy (POCS) was developed as a diagnostic modality for better visualization of bile-duct lesions; however, there is no report on POCS by using NBI. Objective To evaluate the clinical usefulness of POCS by using NBI for the diagnosis of biliary-tract diseases. Design Prospective case study. Setting This procedure was performed at Tokyo Medical University Hospital. Patients Twelve consecutive patients with biliary-tract diseases, including 7 bile-duct cancers and 5 benign biliary diseases, which revealed 6 bile-duct strictures and 6 filling defects by ERCP. Intervention All patients underwent POCS by using NBI. Main Outcome Measurement Efficacy and safety of this technique. Results Twenty-one lesions were evaluated by using POCS with conventional white light imaging and NBI. Although visualization of only 2 lesions (9.5%) was “excellent” by conventional observation, visualization of 12 lesions (57.4%) was “excellent” by NBI observation. Identification of the surface structure and vessels of the lesions by NBI observation was significantly better than with conventional observation ( P < .01 and P < .05, respectively). Limitations Maneuverability and fragility of POCS. The current POCS is not equipped with magnification. Conclusions POCS by using NBI may be helpful for the observation of both fine mucosal structures and tumor vessels.
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