Endoscopic Mucosal Resection and Full Thickness Resection with Complete Defect Closure for Early Gastrointestinal Malignancies

• Indroduction
• Materials and Methods
• Results
• Discussion
• References

Background and Study Aims: We developed a new endoscopic technique, the endoscopic full-thickness resection (EFTR) and endoscopic complete defect closure (ECDC), for the treatment of early gastrointestinal malignancies.

Patients and Methods: Two rectal and one duodenal carcinoid were treated by EFTR with ECDC and resectability, complications and pathological findings were evaluated.

Results: In all cases, the lesion was completely resected without serious complications. The histology of the specimen also confirmed complete resection of the tumor.

Conclusions: This technique has great potential for the treatment of early gastrointestinal malignancies. Preliminary results have shown that early malignant gastrointestinal lesions can be safely and completely resected by EFTR with ECDC.

Indroduction

The Japanese program for early detection of gastric cancer which has been developed over the last two decades has been very successful. Using high-resolution video endoscopy and chromoendoscopy, the detection rate of early gastric cancer has risen sharply; these now represent more than 50 % of all gastric cancers, and half of the early gastric cancers detected are located to the mucosa [1]. A clinicopathological study on early gastric cancer, involving over 4 000 surgically treated patients in Japan, that no lymph node metastasis was seen when the early gastric cancer was of the flat elevated type less than 2 cm in diameter or the depressed type less than 1 cm without ulcer scar [2]. In the light of these data, we now consider these patients to be excellent candidates for curative treatment using endoscopic mucosal resection (EMR). Based on experience with EMR using a ligation device (EMR-L), we have developed a new technique, namely endoscopic full-thickness resesection (EFTR) with the use of a ligation device (EFTR-L) [7], followed by endoscopic complete defect closure (ECDC) (Figure [1]). After animal experiments using porcine stomach and colon under the control of laparoscopy, we have applied this technique in clinical cases.

Materials and Methods

We have performed three EFTR procedures, involving a duodenal carcinoid and two rectal carcinoids. All the procedures were performed using flexible endoscopes under conscious sedation. The malignant lesion was first suctioned using an endoscopic variceal ligation (EVL) device without saline injection. This ligation technique successfully included all layers of the gastrointestinal wall (mucosa, submucosa, and muscularis propria). The integrity of the gastrointestinal wall was then secured using the ECDC device before the lesion was resected. The ECDC device consists of a detachable metallic snare with an inner needle (Figure [2]).

Results

In all cases, the lesion was completely resected without serious complication. In the cases of duodenal carcinoid, the EFTR-L was performed endoluminally using a forward-view upper gastrointestinal endoscope under laparoscopic control. We found a pinhole perforation (a bubble appeared) on the anterior wall of the duodenal bulb and the perforation was simultaneously closed by laparoscopic suture (Figure [3]). The histological examination of the full-thickness resected specimen showed complete resection of the duodenal carcinoid (Figure [4]).

A case of rectal carcinoid resected by EFTR and ECDC, using the detachable metallic snare with an inner needle is illustrated (Figure [5]). The histological examination of the resected specimen showed complete resection of the tumor (Figure [6]).

Discussion

After Tada et al. [3] had reported EMR, originally described as strip biopsy, after lifting the lesion using a submucosal injection of saline. EMR technique was improved by Takekoshi et al. using a two-channel panendoscope with grasping forceps and snare electrocautery [4]. However, when the cancer is located on the lesser curvature of the mid-body or posterior wall of the upper body of the stomach, it can be difficult to perform EMR safely. Therefore, in 1993, we developed endoscopic mucosal resection with ligation (EMR-L), [5] [6] using an EVL device. Using this device, we can achieve a perpendicular position relative to the early gastric cancer, which is very helpful for success in performing a complete resection.

We have treated 550 cases of early gastric cancer and in 400 cases we have used the EMR-L technique. We have obtained a rate of 60.0 % for complete resection (240 cases). However, after EMR-L, we detected incomplete resection in 30 cases (7.5 %), undetermined completeness in 130 cases (32.5 %), and perforation in three cases. In cases of incomplete resection and perforation, the procedure had to be converted to an open surgery. A total of 274 cases were followed up for more than 1 year and we encountered local recurrence in 42 cases (15.3 %); 10 of these were treated by open surgery and the rest by repeat EMR, endoscopic Nd:YAG or diode laser therapy, or argon plasma coagulation therapy (Table [1]). Based on these experiences, we developed EFTR and ECDC. This technique is characterized by: curability with wider and deeper resection; safety, with no perforation or massive bleeding; lower invasiveness, with no general anesthesia; and exact pathological diagnosis with a wider surgical margin. This technique has great potential for application to early gastrointestinal malignancies. Preliminary experience suggests that early malignant gastrointestinal lesions can be safely and completely resected by selective application of EMR-L and EFTR-L with ECDC.

References

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• 3 Tada M, Shimada M, Murakami F, et al. Development of the strip-off biopsy (in Japanese, English abstract).  Gastroenterol Endosc. 1984;  26 833-839
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• 4 Takekoshi T, Takagi K, Katoh Y, et al. Evaluation of endoscopic resection by double snare method for early gastric cancer (in Japanese, English abstract).  Endosc Dig. 1989;  1 163-177
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• 5 Masuda K, Fujisaki J, Suzuki H, et al. Endoscopic mucosal resection using a ligating device (EMR-L) (in Japanese, English abstract).  Endosc Dig. 1993;  5 1215-1219
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• 7 Suzuki H, Okuwaki S, Ikeda K, et al. Endoscopic full-thickness resection (EFTR) and waterproof defect closure (ENDC) for improvement of curability and safety in endoscopic treatment of early gastrointestinal malignancies (in Japanese, English abstract).  Prog Dig Endosc. 1998;  52 49-53
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H. Suzuki, M.D.

Dept. of Endoscopy
Jikei University School of Medicine

3-25-8 Nishishinbashi
Minato-ku
Tokyo
105-8461 Japan


Fax: Fax:+ 81-3-34594524

Email: E-mail:endosc-taka@jikei.ac.jp

References

• 1 Suzuki H. Endoscopic treatment of early cancer in Japan. Have we reached the limit?.  Endoscopy. 1998;  30 578
  PubMedSearch in Google Scholar
• 2 Ohshiba S, Ashida K, Tanaka M, et al. Curative endoscopic resection of early gastric cancer. The possibility of extending its indication (in Japanese, English abstract).  Stomach Intest. 1993;  28 1421-1426
  PubMedSearch in Google Scholar
• 3 Tada M, Shimada M, Murakami F, et al. Development of the strip-off biopsy (in Japanese, English abstract).  Gastroenterol Endosc. 1984;  26 833-839
  PubMedSearch in Google Scholar
• 4 Takekoshi T, Takagi K, Katoh Y, et al. Evaluation of endoscopic resection by double snare method for early gastric cancer (in Japanese, English abstract).  Endosc Dig. 1989;  1 163-177
  PubMedSearch in Google Scholar
• 5 Masuda K, Fujisaki J, Suzuki H, et al. Endoscopic mucosal resection using a ligating device (EMR-L) (in Japanese, English abstract).  Endosc Dig. 1993;  5 1215-1219
  PubMedSearch in Google Scholar
• 6 Okuwaki S. Experimental and clinicopathological study on endoscopic mucosal resection for early gastric cancer - aiming at safe and reliable resection (in Japanese, English abstract).  Tokyo Jikeikai Med J. 1995;  110 561-576
  PubMedSearch in Google Scholar
• 7 Suzuki H, Okuwaki S, Ikeda K, et al. Endoscopic full-thickness resection (EFTR) and waterproof defect closure (ENDC) for improvement of curability and safety in endoscopic treatment of early gastrointestinal malignancies (in Japanese, English abstract).  Prog Dig Endosc. 1998;  52 49-53
  PubMedSearch in Google Scholar

H. Suzuki, M.D.

Dept. of Endoscopy
Jikei University School of Medicine

3-25-8 Nishishinbashi
Minato-ku
Tokyo
105-8461 Japan


Fax: Fax:+ 81-3-34594524

Email: E-mail:endosc-taka@jikei.ac.jp