Case Study
Endoscopic submucosal dissection with insulated-tip knife for large mucosal early gastric cancer: a feasibility study (with videos)

https://doi.org/10.1016/j.gie.2007.03.1059Get rights and content

Background

According to clinicopathologic studies, differentiated-type mucosal early gastric cancers without ulcer or ulcer scar have little risk of lymph-node metastasis, irrespective of tumor size. However, patients with large mucosal early gastric cancer have been subjected to surgery because conventional EMR methods could not resect large tumors en bloc.

Objective

To evaluate the feasibility and the efficacy of endoscopic submucosal dissection for treatment of early gastric cancers larger than 3 cm in diameter.

Design

Case series study.

Setting

Referral cancer center.

Patients

A total of 30 consecutive patients were enrolled with the following characteristics: diagnosis of differentiated-type early gastric cancer larger than 3 cm, lack of ulcerative change, no endoscopic evidence for submucosal invasion, and no evidence of lymph-node or distant metastasis (22 men and 8 women; median age, 69 years; median tumor size, 40 mm).

Interventions

Tumors were resected by endoscopic submucosal dissection with an insulated-tip knife.

Main Outcome Measurements

Complete resection, complication rate, and operation time.

Results

Complete resection was obtained in 23 of 30 cases (77%). Complications included hemorrhage (n = 4), perforation (n = 1), and pyloric stenosis (n = 1), but no severe complications occurred that required surgery or that led to major morbidity. Complete resection and complication rates improved in the last 10 cases (90% and 0%, respectively), though operation time was not shortened.

Limitations

Small sample size and lack of controls.

Conclusions

Endoscopic submucosal dissection when using the insulated-tip knife is feasible and efficacious for selected patients with mucosal early gastric cancer larger than 3 cm.

Section snippets

Patients and methods

This was a prospective case series study performed at an endoscopy unit at the Osaka Medical Center for Cancer and Cardiovascular Disease. An endoscopist (N.U.) who has experienced 7800 EGDs and 180 conventional EMRs performed all procedures.

Observations

Between July 2002 and December 2004, 95 patients with EGC larger than 3 cm presented to our center. Of them, 32 patients who were diagnosed as having submucosal EGC, 23 patients with intramucosal EGC with ulcer or scar, and 10 patients with undifferentiated-type mucosal EGC underwent gastrectomy. Thus, a total of 30 consecutive patients were enrolled (Fig. 2). Characteristics of the subjects are shown in Table 1. We divided the 30 patients into 3 groups of 10 (1st, 2nd, and 3rd) to assess the

Discussion

In this case series study, we demonstrated the technical feasibility of ESD for large intramucosal EGC with the IT knife. The possibility for cure from large intramucosal EGC by endoscopic resection could be demonstrated by complete removal of the tumor and assurance of a lack of lymph-node metastasis by histologic examination. En bloc resection is not absolutely necessary for complete removal of the tumor but is strongly preferred to piecemeal resection for elimination of local recurrence and

References (22)

  • T. Nakajima

    Gastric cancer treatment guidelines in Japan

    Gastric Cancer

    (2002)
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