Principles of Quality Controlled Endoscopic Submucosal Dissection with Appropriate Dissection Level and High Quality Resected Specimen

Takashi Toyonaga,Eisei Nishino,Mariko Man-i,James E. East,Takeshi Azuma 대한소화기내시경학회 2012 Clinical Endoscopy Vol.45 No.4

Endoscopic submucosal dissection (ESD) has enabled en bloc resection of early stage gastrointestinal tumors with negligible risk of lymph node metastasis, regardless of tumor size, location, and shape. However, ESD is a relatively difficult technique compared with conventional endoscopic mucosal resection, requiring a longer procedure time and potentially causing more complications. For safe and reproducible procedure of ESD, the appropriate dissection of the ramified vascular network in the level of middle submucosal layer is required to reach the avascular stratum just above the muscle layer. The horizontal approach to maintain the appropriate depth for dissection beneath the vascular network enables treatment of difficult cases with large vessels and severe fibrosis. The most important aspect of ESD is the precise evaluation of curability. This approach can also secure the quality of the resected specimen with enough depth of the submucosal layer.

Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum

Nobuaki Ikezawa,Takashi Toyonaga,Shinwa Tanaka,Tetsuya Yoshizaki,Toshitatsu Takao,Hirofumi Abe,Hiroya Sakaguchi,Kazunori Tsuda,Satoshi Urakami,Tatsuya Nakai,Taku Harada,Kou Miura,Takahisa Yamasaki,Stu 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.3

Background/Aims: Endoscopic submucosal dissection (ESD) for diverticulum-associated colorectal lesions is generally contraindicatedbecause of the high risk of perforation. Several studies on patients with such lesions treated with ESD have been reported recently. However, the feasibility and safety of ESD for lesions in proximity to a colonic diverticulum (D-ESD) have not been fully clarified. Theaim of this study was to evaluate the feasibility and safety of D-ESD. Methods: D-ESD was defined as ESD for lesions within approximately 3 mm of a diverticulum. Twenty-six consecutive patients whounderwent D-ESD were included. Two strategic approaches were used depending on whether submucosal dissection of the diverticulum-related part was required (strategy B) or not (strategy A). Treatment outcomes and adverse events associated with each strategywere analyzed. Results: The en bloc resection rate was 96.2%. The R0 and curative resection rates were 76.4% and 70.6% in strategy A and 88.9% and77.8% in strategy B, respectively. Two cases of intraoperative perforation and one case of delayed perforation occurred. The delayed perforationcase required emergency surgery, but the other cases were managed conservatively. Conclusions: D-ESD may be a feasible treatment option. However, it should be performed in a high-volume center by expert handsbecause it requires highly skilled endoscopic techniques.

Clinical Impact of Different Reconstruction Methods on Remnant Gastric Cancer at the Anastomotic Site after Distal Gastrectomy

Kei Matsumoto,Shinwa Tanaka,Takashi Toyonaga,Nobuaki Ikezawa,Mari Nishio,Masanao Uraoka,Tomoatsu Yoshihara,Hiroya Sakaguchi,Hirofumi Abe,Tetsuya Yoshizaki,Madoka Takao,Toshitatsu Takao,Yoshinori Morit 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.1

Background/Aims: The anastomotic site after distal gastrectomy is the area most affected by duodenogastric reflux. Differentreconstruction methods may affect the lesion characteristics and treatment outcomes of remnant gastric cancers at the anastomoticsite. We retrospectively investigated the clinicopathologic and endoscopic submucosal dissection outcomes of remnant gastriccancers at the anastomotic site. Methods: We recruited 34 consecutive patients who underwent endoscopic submucosal dissection for remnant gastric cancer at theanastomotic site after distal gastrectomy. Clinicopathology and treatment outcomes were compared between the Billroth II and non-Billroth II groups. Results: The tumor size in the Billroth II group was significantly larger than that in the non-Billroth II group (22 vs. 19 mm;p=0.048). More severe gastritis was detected endoscopically in the Billroth II group (2 vs. 1.33; p=0.0075). Moreover, operation timewas longer (238 vs. 121 min; p=0.004) and the frequency of bleeding episodes was higher (7.5 vs. 3.1; p=0.014) in the Billroth IIgroup. Conclusions: Compared to remnant gastric cancers in non-Billroth II patients, those in the Billroth II group had larger lesions with abackground of severe remnant gastritis. Endoscopic submucosal dissection for remnant gastric cancers in Billroth II patients involvedlonger operative times and more frequent bleeding episodes than that in patients without Billroth II.

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)

Management of esophageal neoplasms by endoscopic submucosal dissection: experience over 100 consecutive procedures

Josué Aliaga Ramos,Yoshinori Morita,Takashi Toyonaga,Danilo Carvalho,Moises Salgado Pedrosa,Vitor N. Arantes 대한소화기내시경학회 2023 Clinical Endoscopy Vol.56 No.5

Background/Aims: Endoscopic submucosal dissection (ESD) is currently considered the first-line treatment for the eradication of superficialneoplasms of the esophagus in Eastern countries. However, in the West, particularly in Latin America, the experience withesophageal ESD is still limited because of the high technical complexity required for its execution. This study aimed to present the resultsof the clinical application of ESD to manage superficial esophageal neoplasms in a Latin American center in over 100 consecutivecases. Methods: This retrospective study included consecutive patients who underwent endoscopic ESD for superficial esophageal neoplasmsbetween 2009 and 2022. The following clinical outcomes were assessed: en bloc, complete, and curative resection rates, local recurrence,adverse events, and procedure-related mortality. Results: Esophageal ESD was performed mainly for squamous cell carcinoma (66.6%), high-grade intraepithelial neoplasia (17.1%),and adenocarcinoma (11.4%). En bloc and complete resection rates were 96.2% and 81.0%, respectively. The curative resection rate was64.8%. Adverse events occurred in six cases (5.7%). Endoscopic follow-up was performed for an average period of 29.7 months. Conclusions: ESD performed by trained operators is feasible, safe, and clinically effective for managing superficial neoplastic lesions ofthe esophagus in Latin America.

Reasons for Diagnostic Failure in Forty-Five Consecutive Mucosal Cutting Biopsy Examinations of Gastric Subepithelial Tumors

Yoshiko Nakano,Toshitatsu Takao,Yoshinori Morita,Shinwa Tanaka,Takashi Toyonaga,Eiji Umegaki,Yuzo Kodama 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.5

Background/Aims: Mucosal cutting biopsy (MCB) is useful for the histopathological diagnosis of gastric subepithelial tumors (SETs). However, there is little information on cases in which MCB did not establish a diagnosis. In the current study, we aimed to investigatethe characteristics of cases in which MCB was unsuccessful. Methods: Cases in which MCB was used to histopathologically diagnose gastric SETs at Kobe University Hospital between August 2012and October 2018 were retrospectively reviewed. Results: Forty-five cases in which MCB was used to diagnose 43 gastric SETs in 43 patients were analyzed. The median tumor sizewas 20 mm (range, 8–50 mm). Pathological examinations resulted in definitive and suspected diagnoses and no diagnosis in 29(gastrointestinal stromal tumor: n=17, leiomyoma: n=7, aberrant pancreas: n=3, others: n=2), 6, and 10 cases, respectively. Failure toexpose the tumor according to retrospective examinations of endoscopic images was significantly associated with no diagnosis. Otherpossible explanations included a less elevated tumor, biopsy of the surrounding field instead of the tumor due to the mobility, and poorendoscope maneuverability due to the tumor being close to the cardia. Conclusions: Clear exposure of gastric SETs during MCB may improve the diagnostic rate of such examinations.

Efficacy of the Envelope Method in Applying Polyglycolic Acid Sheets to Post-Endoscopic Submucosal Dissection Ulcers in Living Pigs

Hiroya Sakaguchi,Toshitatsu Takao,Yoshitaka Takegawa,Yuki Koga,Kazunori Yamanaka,Masataka Sagata,Shinwa Tanaka,Yoshinori Morita,Takashi Toyonaga,Yuzo Kodama 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.1

Background/Aims: Application of polyglycolic acid (PGA) sheets using fibrin glue in post-endoscopic submucosal dissection (ESD)ulcers to prevent bleeding has been reported to be difficult with the conventional delivery method because of gravity. This studyassessed the usefulness of the envelope-based delivery system with and against gravity in living pigs. Methods: PGA sheets were applied on post-ESD ulcers with and against gravity six times each using the conventional and envelopemethods, respectively. The PGA sheet delivery time and the endoscopic and histological findings of the treated ulcer floors werecompared. Results: With gravity, the median PGA sheet application time was 1.00 (0.68–1.30) min/cm2 and 0.32 (0.18–0.52) min/cm2 with theconventional and envelope techniques (p=0.002), respectively, and against gravity, it was 1.20 (1.13–1.63) min/cm2 and 0.50 (0.39–0.58) min/cm2 (p=0.002), respectively. Against gravity, the endoscopic and histological findings revealed that the conventional grouphad insufficient fixation of the PGA sheets, but the envelope groups had sufficient fixation. The results with gravity were similarbetween the groups. Conclusions: The envelope method makes it possible to deliver PGA sheets to the stomach quickly and cover ulcers appropriatelyboth with and against gravity in living pigs.