The Clinical Accuracy of Endoscopic Ultrasonography and White Light Imaging in Gastric Endoscopic Submucosal Dissection

Park, Soon-Hong,Sung, Sang-Hun,Lee, Seung-Jun,Jung, Min-Kyu,Kim, Sung-Kook,Jeon, Seong-Woo The Korean Gastric Cancer Association 2012 Journal of gastric cancer Vol.12 No.2

Purpose: Gastric mucosal neoplastic lesions should have characteristic endoscopic features for successful endoscopic submucosal dissection. Materials and Methods: Out of the 1,010 endoscopic submucosal dissection, we enrolled 62 patients that had the procedure cancelled. Retrospectively, whether the reasons for cancelling the endoscopic submucosal dissection were consistent with the indications for an endoscopic submucosal dissection were assessed by analyzing the clinical outcomes of the patients that had the surgery. Results: The cases were divided into two groups; the under-diagnosed group (30 cases; unable to perform an endoscopic submucosal dissection) and the over-diagnosed group (32 cases; unnecessary to perform an endoscopic submucosal dissection), according to the second endoscopic findings, compared with the index conventional white light image. There were six cases in the under-diagnosed group with advanced gastric cancer on the second conventional white light image endoscopy, 17 cases with submucosal invasion on endoscopic ultrasonography findings, 5 cases with a size greater than 3 cm and ulcer, 1 case with diffuse infiltrative endoscopic features, and 1 case with lymph node involvement on computed tomography. A total of 25 patients underwent a gastrectomy to remove a gastric adenocarcinoma. The overall accuracy of the decision to cancel the endoscopic submucosal dissection was 40% (10/25) in the subgroup that had the surgery. Conclusions: The accuracy of the decision to cancel the endoscopic submucosal dissection, after conventional white light image and endoscopic ultrasonography, was low in this study. Other diagnostic options are needed to arrive at an accurate decision on whether to perform a gastric endoscopic submucosal dissection.

The Clinical Accuracy of Endoscopic Ultrasonography and White Light Imaging in Gastric Endoscopic Submucosal Dissection

Soon Hong Park,Sang Hun Sung,Seung Jun Lee,정민규,김성국,전성우 대한위암학회 2012 Journal of gastric cancer Vol.12 No.2

Purpose: Gastric mucosal neoplastic lesions should have characteristic endoscopic features for successful endoscopic submucosal dissection. Materials and Methods: Out of the 1,010 endoscopic submucosal dissection, we enrolled 62 patients that had the procedure cancelled. Retrospectively, whether the reasons for cancelling the endoscopic submucosal dissection were consistent with the indications for an endoscopic submucosal dissection were assessed by analyzing the clinical outcomes of the patients that had the surgery. Results: The cases were divided into two groups; the under-diagnosed group (30 cases; unable to perform an endoscopic submucosal dissection) and the over-diagnosed group (32 cases; unnecessary to perform an endoscopic submucosal dissection), according to the second endoscopic findings, compared with the index conventional white light image. There were six cases in the under-diagnosed group with advanced gastric cancer on the second conventional white light image endoscopy, 17 cases with submucosal invasion on endoscopic ultrasonography findings, 5 cases with a size greater than 3 cm and ulcer, 1 case with diffuse infiltrative endoscopic features, and 1 case with lymph node involvement on computed tomography. A total of 25 patients underwent a gastrectomy to remove a gastric adenocarcinoma. The overall accuracy of the decision to cancel the endoscopic submucosal dissection was 40% (10/25) in the subgroup that had the surgery. Conclusions: The accuracy of the decision to cancel the endoscopic submucosal dissection, after conventional white light image and endoscopic ultrasonography, was low in this study. Other diagnostic options are needed to arrive at an accurate decision on whether to perform a gastric endoscopic submucosal dissection.

Clinical Outcome of Endoscopic Submucosal Dissection for Papillary Type Early Gastric Cancer: A Multicenter Study

( Hyun-deok Shin ),( Ki Bae Bang ),( Sun Hyung Kang ),( Hee Seok Moon ),( Jae Kyu Sung ),( Hyun Yong Jeong ),( Dong Kyu Lee ),( Ki Bae Kim ),( Sun Moon Kim ),( Seung Woo Lee ),( Dong Soo Lee ),( Young 대한소화기기능성질환·운동학회 2024 Gut and Liver Vol.18 No.3

Background/Aims: Papillary adenocarcinoma is classified to differentiated-type gastric cancer and is indicated for endoscopic submucosal dissection. However, due to its rare nature, there are limited studies on it. The purpose of this study was to determine the outcome of endoscopic submucosal dissection in patients with papillary-type early gastric cancer and to find the risk factors of lymph node metastasis. Methods: Patients diagnosed with papillary-type early gastric cancer at eight medical centers, who underwent endoscopic submucosal dissection or surgical treatment, were retrospectively reviewed. The clinical results and long-term outcomes of post-endoscopic submucosal dissection were evaluated, and the risk factors of lymph node metastasis in the surgery group were analyzed. Results: One-hundred and seventy-six patients with papillary-type early gastric cancer were enrolled: 44.9% (n=79) in the surgery group and 55.1% (n=97) in the endoscopic submucosal dissection group. As a result of endoscopic submucosal dissection, the en bloc resection and curative resection rates were 91.8% and 86.6%, respectively. The procedure-related complication rate was 4.1%, and local recurrence occurred in 3.1% of patients. Submucosal invasion (odds ratio, 3.735; 95% confidence interval, 1.026 to 12.177; p=0.047) and lymphovascular invasion (odds ratio, 7.636; 95% confidence interval, 1.730 to 22.857; p=0.004) were the risk factors of lymph node metastasis in papillary-type early gastric cancer patients. Conclusions: The clinical results of endoscopic submucosal dissection in papillary-type early gastric cancer were relatively favorable, and endoscopic submucosal dissection is considered safe if appropriate indications are confirmed by considering the risk of lymph node metastasis. (Gut Liver 2024;18:426-433)

The Goals and Pitfalls of Gastric Submucosal Dissection: A Special Focus on Dissection of Lesions with Severe Fibrosis

Tsukasa Ishida,Harold Jacob,Takashi Toyonaga 대한상부위장관ㆍ헬리코박터학회 2014 Korean Journal of Helicobacter Upper Gastrointesti Vol.14 No.3

Endoscopic submucosal dissection (ESD) has enabled en-bloc resection of superficial gastrointestinal tumors regardless of the size or location of the tumor. However ESD still poses a number of challenges for the experienced endoscopist. These challenges include the adaptation of a demanding technique, the higher incidence of complications, and a longer procedure time compared to standard endoscopic procedures. In this article, we describe the performance of ESD using the Flush Knife technique. We emphasize that the most important factor in the performance of ESD using the Flush Knife technique is maintaining the appropriate depth of dissection. Appropriate dissection of the branched vascular network at the mid-submucosal layer is required to reach the avascular stratum just above the muscle layer. This should be accomplished using the horizontal approach, such that the dissection plane remains as horizontal as possible with respect to the muscle layer. This approach will enable the interventional endoscopist to treat difficult cases with large vessels and severe fibrosis. And at the same time will secure high-quality resected specimens with excellent basal margins so that depth of invasion can be assessed very accurately. Endoscopic submucosal dissection (ESD) has enabled en-bloc resection of superficial gastrointestinal tumors regardless of the size or location of the tumor. However ESD still poses a number of challenges for the experienced endoscopist. These challenges include the adaptation of a demanding technique, the higher incidence of complications, and a longer procedure time compared to standard endoscopic procedures. In this article, we describe the performance of ESD using the Flush Knife technique. We emphasize that the most important factor in the performance of ESD using the Flush Knife technique is maintaining the appropriate depth of dissection. Appropriate dissection of the branched vascular network at the mid-submucosal layer is required to reach the avascular stratum just above the muscle layer. This should be accomplished using the horizontal approach, such that the dissection plane re-mains as horizontal as possible with respect to the muscle layer. This approach will enable the interventional endoscopist to treat difficult cases with large vessels and severe fibrosis. And at the same time will secure high-quality resected specimens with excellent basal margins so that depth of invasion can be assessed very accurately. (Korean J Helicobacter Up Gastrointest Res 2014;14:163- 173)

A Case of Pneumorrhachis and Pneumoscrotum Following Colon Endoscopic Submucosal Dissection

장미영,조진웅,오왕국,고성준,한상훈,백훈기,이영재,김지웅,조용근,정금모 대한장연구학회 2013 Intestinal Research Vol.11 No.3

Endoscopic submucosal dissection has been a useful treatment of selected colorectal neoplasia cases. The incidence of perforation related to colorectal endoscopic submucosal dissection is 5-20%. However, while there have been numerous reports regarding retroperitoneal, mediastinal, pleural and subcutaneous emphysema after therapeutic colonoscopy, pneumoscrotum is a relatively rare manifestation of perforation associated with colorectal endoscopic submucosal dissection. In particular, pneumorrhachis, or air within the spinal cord, following therapeutic colonoscopy, is extremely rare. Herein, we report a conservatively treated perforation case as having pneumorrhachis, penumoscrotum, and pneumoperitoneum after colorectal endoscopic submucosal dissection. (Intest Res 2013;11:208-212)

CASE REPORT : A Case of Pneumorrhachis and Pneumoscrotum Following Colon Endoscopic Submucosal Dissection

( Mi Young Jang ),( Jin Woong Cho ),( Wang Guk Oh ),( Sung Jun Ko ),( Shang Hoon Han ),( Hoon Ki Baek ),( Young Jae Lee ),( Ji Woong Kim ),( Yong Keun Cho ),( Gum Mo Jung ) 대한장연구학회 2013 Intestinal Research Vol.11 No.3

Endoscopic submucosal dissection has been a useful treatment of selected colorectal neoplasia cases. The incidence of perforation related to colorectal endoscopic submucosal dissection is 5-20%. However, while there have been numerous reports regarding retroperitoneal, mediastinal, pleural and subcutaneous emphysema after therapeutic colonoscopy, pneumoscrotum is a relatively rare manifestation of perforation associated with colorectal endoscopic submucosal dissection. In particular, pneumorrhachis, or air within the spinal cord, following therapeutic colonoscopy, is extremely rare. Herein, we report a conservatively treated perforation case as having pneumorrhachis, penumoscrotum, and pneumoperitoneum after colorectal endoscopic submucosal dissection. (Intest Res 2013;11:208-212)

The submucosal fibrosis: what does it mean for colorectal endoscopic submucosal dissection?

( Eun Kyoung Kim ),( Dong Soo Han ),( Youngouk Ro ),( Chang Soo Eun ),( Kyo-sang Yoo ),( Young-ha Oh ) 대한장연구학회 2016 Intestinal Research Vol.14 No.4

Background/Aims: Endoscopic submucosal dissection (ESD) allows removal of colorectal epithelial neoplasms en bloc regardless of size. Colorectal ESD is a difficult procedure because of technical difficulties and risks of complications. This study aimed to assess the relationship between ESD outcome and degree of submucosal fibrosis. Methods: Patients with colorectal tumors undergoing ESD and their medical records were reviewed retrospectively. The degree of submucosal fibrosis was classified into three types. The relationship between ESD outcome and degree of submucosal fibrosis was analyzed. Results: ESD was performed in 158 patients. Thirty-eight cases of F0 (no) fibrosis (24.1%) and 46 cases of F2 (severe) fibrosis (29.1%) were observed. Complete resection was achieved for 138 lesions (87.3%). Multivariate analysis demonstrated that submucosal invasion of tumor and histology of carcinoma were independent risk factors for F2 fibrosis. Severe fibrosis was an independent risk factor for incomplete resection. Conclusions: Severe fibrosis is an important factor related to incomplete resection during colorectal ESD. In cases of severe fibrosis, the rate of complete resection was low even when ESD was performed by an experienced operator. Evaluation of submucosal fibrosis may be helpful to predict the submucosal invasion of tumors and technical difficulties in ESD. (Intest Res 2016;14:358-364)

A Novel One-Step Knife Approach Can Reduce the Submucosal Injection Time of Endoscopic Submucosal Dissection: A Single-Blinded Randomized Multicenter Clinical Trials

( Hyunil Kim ),( Jin Woo Kim ),( Hong Jun Park ),( Su Young Kim ),( Hyun-soo Kim ),( Gwang Ho Baik ),( Sung Chul Park ),( Sang Jin Lee ),( Tae-hwa Go ) 대한소화기학회 2022 Gut and Liver Vol.16 No.1

Background/Aims: Endoscopic submucosal dissection (ESD) is a curative treatment modality for early gastric neoplasms; however, ESD can be a time-consuming process. To overcome this pitfall, we developed the one-step knife (OSK) approach, which combines an endoscopic knife and injection needle on a single sheath. We aimed to evaluate whether this approach could reduce the ESD procedure time. Methods: This single-blinded randomized multicenter trial at four tertiary hospitals from June 2019 to June 2020 included patients aged 19 to 85 years undergoing ESD. Patients were randomly assigned to two groups (OSK or conventional knife [CK]). The injection time, total procedure time, resected specimen size, submucosal fluid amount, degree of device satisfaction, and adverse events were evaluated and compared between groups. Results: Fifty-one patients were analyzed (OSK: 25 patients and CK: 26 patients). No baseline differences were observed between groups, with the exception of a higher portion of males in the OSK group. The mean injection time was significantly reduced in the OSK group (39.0 seconds) compared to that in the CK group (87.5 seconds, p<0.001). A decrease of more than 10 minutes in the total procedure time (18.0 minutes vs 28.1 minutes, p=0.055) in the OSK group compared to the CK group was observed. Second-look esophagogastroduodenoscopy revealed two delayed bleeding cases in the OSK group that were easily controlled by endoscopic hemostasis. Conclusions: OSK reduced the injection time and showed a decrease in total procedure time compared with the CK approach. OSK can be a feasible tool for ESD, especially in difficult cases. (Gut Liver 2022;16:44-52)

ORiginal Article : Endoscopic and Clinical Factors Affecting the Prognosis of Colorectal Endoscopic Submucosal Dissection-Related Perforation

( Dong Uk Kang ),( Yunsik Choi ),( Ho Su Lee ),( Hyo Jeong Lee ),( Sang Hyoung Park ),( Dong Hoon Yang ),( Soon Man Yoon ),( Kyung Jo Kim ),( Byong Duk Ye ),( Seung Jae Myung ),( Suk Kyun Yang ),( Jin 대한간학회 2016 Gut and Liver Vol.10 No.3

Background/Aims: Although colorectal endoscopic submucosal dissection (ESD)-related perforation is not uncommon, the factors affecting clinical outcomes after perforation have not been investigated. This study was designed to investigate the factors influencing the clinical course of ESD-related colon perforation. Methods: Forty-three patients with colorectal ESD-related perforation were evaluated. The perforations were classified as endoscopic or radiologic perforations. The patients’ medical records and endoscopic pictures were analyzed. Results: The clinical outcomes were assessed by the duration of nil per os, intravenous antibiotics administration, and hospital stays, which were 2.7±1.5, 4.9±2.3, and 5.1±2.3 days, respectively. Multivariate analyses revealed that a larger tumor size, ESD failure, specific endoscopists, and abdominal pain were independently related to a poorer outcome. The time between perforation and clipping was 15.8±25.4 minutes in the endoscopic perforation group. The multivariate analysis of this group indicated that delayed clipping, specific endoscopists, and abdominal pain were independently associated with poorer outcomes. Conclusions: Tumor size, ESD failure, abdominal pain, and the endoscopist were factors that affected the clinical outcomes of patients with colorectal ESD-related perforation. The time between the perforation and clipping was an additional factor influencing the clinical course of endoscopic perforation. Decreasing this time period may improve outcomes. (Gut Liver 2016;10:420-428)

History and Development of Accessories for Endoscopic Submucosal Dissection

고봉민 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.3

Endoscopic submucosal dissection (ESD) procedure is composed of circumferential mucosal incision and submucosal dissection. A variety of endoscopic accessories are required to perform mucosal incision and submucosal dissection safely. As a result of the improvements in ESD devices and peripheral equipment and development of the ESD technique, ESD procedures have been performed extensively worldwide. Here I review the history of the development of accessories used in performing ESD procedures.