Fukami, Norio

Abstract Background and study aims The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68–138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

INTRODUCTION: While esophagectomy is the standard treatment for submucosal (T1b) esophageal adenocarcinoma (EAC) and squamous cell cancer (SCC), many elderly patients -the age group that esophageal cancer tends to affect- are not candidates for surgery. Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that allows for en-bloc resection of early esophageal cancer and allows for precise histopathologic staging of the tumor. ESD could be curative in submucosal cancer without lymph node metastasis, and it allows for precise histopathologic staging. To evaluate the long-term outcomes of ESD in patients with EUS-staged T1b esophageal cancer. METHODS: A retrospective multicenter study was performed at three academic hospitals in the U.S. Patients who underwent ESD with a pre-procedural or post-procedural histopathologic diagnosis of T1b N0 M0 EAC or SCC were included in the study. Data was collected on demographics, tumor and procedure characteristics, procedure pathology, and follow-up. Local recurrence was confirmed by endoscopic findings and pathological analysis. Metastasis was confirmed by cross-sectional imaging. The main outcome was a composite of rate of metastasis and local recurrence. Follow-up time was defined as months from initial procedure to recurrence or last follow-up visit if recurrence-free. A time-to-event analysis was performed to evaluate recurrence. RESULTS: Fifty-two patients underwent ESD (mean age 69.6 years +/-9; 35 males) (Table 1). Based on available comorbidity data, 42% patients were not fit for surgery, as determined by an age-adjusted Charlson Comorbidity Index > 6. Twenty tumors (62%) were found to be HGD or T1a on post-ESD specimen analysis, while one was staged as T2. Nineteen patients were staged as T1b after ESD. Immediately after ESD, 6 patients were referred for surgery, 3 underwent chemoradiation therapy, and 6 radiation alone (Table 2). Patients were followed for a median of 18 months, and the calculated 24-month recurrence rate was 13% (Figure 1). CONCLUSION: This multicenter trial showed that ESD for T1b esophageal cancer can be acceptable for patients who deemed not surgical candidates. However, close follow up is necessary. ESD can also serve as a staging procedure, as our data confirms inaccurate EUS-staging of T1b cancer, with 62% of tumors being down-staged to T1a, as has been previously reported.

INTRODUCTION: The difference in long-term outcomes of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for Barrett’s related superficial neoplasia remains unclear. We aimed to compare the rates of local and metachronous recurrence of ESD and EMR in patients with clinically staged BE-associated high-grade dysplasia (HGD) and T1a esophageal adenocarcinoma (EAC). METHODS: Multicenter study at six academic hospitals in the U.S. including patients who underwent ESD for BE-HGD or T1a EAC. Primary outcome was a composite of metastasis and local recurrence rate. A time-to-event analysis was performed to evaluate recurrence. A Kaplan-Meier plot was constructed, and a log-rank test was used to compare the groups. A Cox hazard ratio regression analysis was performed to identify predictors of recurrence. RESULTS: A total of 241 patients were included. 154 underwent EMR, while 84 underwent ESD (Table 1). ESD had higher en bloc (96% vs 33%, P < 0.0001), R0 (76% vs 54%, P = 0.0009) and curative resection rates (75% vs 32%, P < .0001) when compared to EMR. The 24-month local recurrence rate for EMR and ESD was 43% and 11%, respectively ( P = 0.0007) (Figure 1). Significantly more endoscopic resection procedures were required to treat recurrence after EMR compared to after ESD (Table 1). EMR, piecemeal resection, positive margins, and non-curative resection were identified as predictors of recurrence on univariate analysis. En bloc resection remained significant after multivariate analysis (Table 2). CONCLUSION: This multicenter study showed that ESD results in more definitive treatment of BE-associated early neoplasia than EMR, with significant lower recurrence rates and less need for repeat endoscopic therapeutic procedures than EMR.

BackgroundAccurate staging of superficial esophageal squamous cell cancer (ESCC) for endoscopic therapy is challenging. Optical coherence tomography (OCT) has been shown to be superior to high‐resolution endoscopic ultrasound (EUS). Volumetric Laser Endomicroscopy (VLE), a second‐generation OCT, has recently become commercially available.ObjectiveTo assess if VLE can determine which patients with superficial ESSC can undergo endoscopic therapy.MethodsThis is a multi‐center retrospective study. Patients were included if (a) they had visible ESCC, (b) they underwent VLE and EUS for staging, and c) if superficial disease was suspected then endoscopic resection had to be performed to have accurate histology to compare the VLE scan to. VLE scans were then compared to the gold standard: histology for superficial disease and EUS for disease T1b and greater.ResultsSeventeen patients were included with the following disease: squamous intraepithelial neoplasia (4 patients), T1a disease (6 patients), T1b (2 patients), T2 disease (2 patients) and T3 disease (3 patients). VLE was able to distinguish superficial disease, defined as disease limited up to the lamina propria, from non‐superficial disease in all cases.ConclusionsVLE may be able to determine which ESCC patients are candidates for endoscopic therapy. Prospective studies are needed to confirm this.