Effectiveness of modified oral steroid administration for preventing esophageal stricture after entire circumferential endoscopic submucosal dissection.

Esophageal stricture occurs at a high rate after endoscopic submucosal dissection, especially after entire circumferential dissection, leading to poor quality of life. This retrospective cohort study evaluated the stricture rate in circumferential mucosal defect cases following modified steroid administration. We enrolled 22 consecutive patients who underwent entire circumferential endoscopic submucosal dissection for superficial esophageal cancer between April 2010 and April 2015 at our hospital. Until January 2013, a systemic steroid-prednisolone-was administered at 30 mg/day and tapered over 8 weeks in the original method group (original group). From February 2013, 30 mg of prednisolone was administered orally for 3 weeks and then the dose was reduced in 5 mg decrements every 3 weeks. This group was classified as the modified method group (modified group). We retrospectively compared the stricture rates between the two groups. The postoperative stricture rate was significantly lower in the modified group (36.4%; 4/11 patients) than in the original group (82%; 9/11 patients; P = 0.04). The mean number of endoscopic balloon dilatation procedures was significantly lower in the modified group (6.2 ± 11.3) than in the original group (19.4 ± 15.3; P = 0.023). Pneumonia and oral herpes infection, which are adverse events potentially associated with steroid administration, were observed in the original group. Candida esophagitis, arthritis, and steroid-related myopathy were observed in the modified group. This modified systemic steroid administration was effective for patients with entire circumferential mucosal defect. The safety of this method was also demonstrated.

Polyglycolic acid sheet and fibrin glue for preventing esophageal stricture after endoscopic submucosal dissection: a historical control study.

There have been several reports that steroid administration is effective at preventing strictures after endoscopic submucosal dissection (ESD). However, adverse events after steroid use are of great concern. We have reported that shielding with a polyglycolic acid (PGA) sheet and fibrin glue can be useful for prevention of stricture after ESD. We conducted a retrospective analysis of efficiency of shielding with a PGA sheet and fibrin glue for prevention of esophageal stricture compared with intralesional steroid injection. ESD was performed on a total of 489 lesions in 400 patients for superficial esophageal cancer from January 2012 to July 2016. Of these, 39 lesions were enrolled in the study group (PGA sheet and fibrin glue) and 31 lesions were enrolled in the control group. The incidence of postoperative stricture at 6 weeks and the number of sessions of endoscopic balloon dilatation (EBD) required to resolve any strictures were evaluated. The post-ESD stricture rate was 9.1% in the study group (3/33 patients), which was not significantly lower than the stricture rate of 10.3% in the historical control group (3/29 patients; p = 1.00). The mean number of EBD was 0.057 ± 0.24 in the study group and 1.9 ± 5.1 in the control group, which was not significant (P = 0.95). PGA sheet and fibrin glue appear to be a promising option for the prevention of esophageal stricture similar to the effect of intralesional steroid injection.

Vascular density of superficial esophageal squamous cell carcinoma determined by direct observation of resected specimen using narrow band imaging with magnifying endoscopy.

Observation of the microvasculature using narrow band imaging (NBI) with magnifying endoscopy is useful for diagnosing superficial squamous cell carcinoma. Increased vascular density is indicative of cancer, but not many studies have reported differences between cancerous and noncancerous areas based on an objective comparison. We observed specimens of endoscopic submucosal dissection (ESD) using NBI magnification, and determined the vascular density of cancerous and noncancerous areas. A total of 25 lesions of esophageal squamous cell carcinoma that were dissected en bloc by ESD between July 2013 and December 2013 were subjected to NBI magnification. We constructed a device that holds an endoscope and precisely controls the movement along the vertical axis in order to observe submerged specimens by NBI magnification. NBI image files of both cancerous (pathologically determined invasion depth, m1/2) and surrounding noncancerous areas were created and subjected to vascular density assessment by two endoscopists who were blinded to clinical information. The invasion depth was m1/2 in 20, m3/sm1 in four and sm2 in one esophageal cancer lesion. Mean vascular density was significantly increased in cancerous areas (37.6 ± 16.3 vessels/mm2) compared with noncancerous areas (17.6 ± 10.0 vessels/mm2) (P < 0.05). The correlation coefficients between vascular density determined by two endoscopists were 0.86 and 0.81 in cancerous and noncancerous areas, respectively. Receiver operating curve (ROC) analysis revealed that the area under the curve (AUC) of vascular density was 0.895 (95% CI, 0.804-0.986). For this ROC curve, sensitivity was 78.3% and specificity was 87.0% when the cutoff value of vascular density was 26 vessels/mm2. NBI magnification confirmed significant increases in vascular density in cancerous areas compared with noncancerous areas in esophageal squamous cell carcinoma. The rates of agreement between vascular density values determined by two independent operators were high.

Clinical advantage of endoscopic submucosal dissection over endoscopic mucosal resection for early mesopharyngeal and hypopharyngeal cancers.

BACKGROUND AND STUDY AIMS: In previous series, endoscopic mucosal resection (EMR) has been used for the treatment of early-stage mesopharyngeal and hypopharyngeal cancers to preserve patients' quality of life. Endoscopic submucosal dissection (ESD) offers potential advantages in comparison to EMR. So the aim of this retrospective study was to assess the utility of ESD compared with EMR for early-stage cancers of the meso- and hypopharynx. PATIENTS AND METHODS: We studied 56 patients with 69 lesions who underwent either EMR or ESD between April 2001 and December 2008. EMR was performed until January 2007, and ESD was performed from February 2007 onward. We evaluated the en bloc resection rate, R0 resection rate, and treatment-related complications as short-term outcomes. Local recurrence, lymph node metastasis, and disease-related deaths were compared to evaluate long-term outcomes. RESULTS: The en bloc and R0 resection rates were respectively 98 % and 79 % in the ESD group and 37 % and 26 % in the EMR group. There were no cases of treatment-related complications in the EMR group, but postoperative subcutaneous emphysema was observed in two patients in the ESD group. In the EMR group, one patient developed a local recurrence and one developed metastasis to the cervical lymph node and died of primary cancer. CONCLUSIONS: ESD is a useful method of treatment for early mesopharyngeal and hypopharyngeal cancers and may be superior to EMR.

Recurrence rate of intramucosal gastric cancer with positive vertical margin due to lesion damage during endoscopic submucosal dissection.

BACKGROUND AND STUDY AIM: In principle, additional surgery is performed after endoscopic submucosal dissection for early gastric cancer if the vertical margin is positive, regardless of lesion damage. The recurrence rate of vertical margin-positive lesions due to lesion damage after endoscopic submucosal dissection is unknown, and unnecessary surgeries may be performed. In this study, we investigated whether there was a difference in the recurrence rate between vertical margin-positive lesions due to lesion damage and vertical margin-negative lesions. PATIENTS AND METHODS: We included 1,294 intramucosal gastric cancer lesions that were resected by endoscopic submucosal dissection between January 2008 and December 2016, without additional surgery. The lesions were divided into the Damage and No damage groups based on vertical margin status. The Damage group had only one non-curative indication: a positive vertical margin due to lesion damage. The No damage group had no non curative indications. We compared the recurrence rate between the Damage and No damage groups. RESULTS: The recurrence rates of the Damage and No damage groups were 0% (0/23; 95% confidence interval: 0-14.8%) and 0% (0/1,271; 95% confidence interval: 0-0.003%), respectively, with no statistically significant difference. CONCLUSIONS: In intramucosal gastric cancer, the recurrence rate of vertical margin-positive lesions due to lesion damage was 0%, which did not differ from that of vertical margin-negative lesions with curative resection. Follow-up, instead of additional surgery, may be an option for patients with non-curative resection when the only non-curative indication is a positive vertical margin due to lesion damage.

Endoscopic submucosal dissection for treatment of mesopharyngeal and hypopharyngeal carcinomas.

BACKGROUND AND STUDY AIMS: Application of the endoscopic submucosal dissection (ESD) technique, as well as elevation of the larynx in cooperation with an otolaryngologist, under general anesthesia has enabled en-block resection of early mesopharyngeal and hypopharyngeal carcinomas. The aim of this study was to retrospectively evaluate the safety of ESD and the efficacy of the elevation of the larynx for treatment of early mesopharyngeal and hypopharyngeal carcinomas. PATIENTS AND METHODS: The study included 16 lesions in 13 patients who underwent ESD. To provide a sufficient working space, the larynx was elevated under direct laryngoscopy, and a tube was inserted and fixed onto the laryngeal side using the slot on the back of the laryngoscope. RESULTS: The median maximum diameter of the lesions was 12.5 mm (range 2 - 37 mm). The en-block resection rate was 93.8 %. Lateral surgical margins in two patients were difficult to evaluate for technical reasons. The tube could not be removed from four patients on the day of the procedure due to laryngeal edema caused by the local injection. No serious complications were observed. Oral food intake was possible after a mean of 3.3 postoperative days. CONCLUSIONS: With adequate intraoperative and postoperative management, ESD with elevation of the larynx may be very efficient and safe for endoscopic treatment of pharyngeal lesions.