Background and Study Aims: Endoscopic mucosal resection (EMR) of early gastrointestinal cancers has been shown
to be effective in treating mucosal malignancies, but en bloc resection (where the
entire tumor is removed in one piece) is often not achieved using conventional cap
EMR. Other techniques, developed in Japan, include the application of different types
of knife such as the insulated-tip instrument. We report our preliminary experience
of the use of this knife, in conjunction with other techniques, in attempting en bloc
resection of early mucosal cancers and adenomas and in the removal of submucosal tumors
(SMTs) of the upper gastrointestinal tract. Patients and Methods: A total of 37 patients (26 men, 11 women, age range 53 - 86) were included in the
study; 23 patients had 24 mucosal lesions amenable to EMR, and 14 patients had SMTs
shown on endosonography to spare the muscularis propria. Lesions were located in the
esophagus (n = 13), the stomach (n = 24), and the duodenum (n = 1); 40 % of the mucosal
lesions were 20 mm or larger (mean size 18mm), whereas the mean size of the submucosal
lesions was 23 mm. After submucosal saline injection, circumcision and dissection
of the mucosal lesions was attempted with the aim of achieving en bloc resection.
For SMTs, cap mucosectomy of the overlying mucosa was done first, and the tumors were
then freed using saline injection, and finally resected using snare polypectomy. Results: The strict aim of the study, i. e. complete tumor removal in a single piece, was
achieved in only 25 % of the mucosal lesions (some failures were due to unrecognized
submucosal infiltration) and 36 % of the SMTs. When a more liberal definition of success
was assumed, this rate increased to 65 % for mucosal lesions (piecemeal, no tumor
found at surgery or follow-up endoscopy with biopsy) and 79 % for SMTs (piecemeal).
No severe complications necessitating surgery or leading to major morbidity occurred.
However, clinically significant complications were found in six patients (minor perforation
managed conservatively (n = 1), severe pain without perforation (n = 1), bleeding
requiring reintervention (n = 3), and aspiration (n = 1)). Conclusions: Although we are convinced that methods of achieving en bloc resection of mucosal
cancers and SMTs must be pursued, the insulated-tip knife in conjunction with conventional
endoscopes still has limitations. Innovative endoscope design (double-channel scopes)
as well as the development of new accessories will help to overcome the current limitations
and further promote endoscopic tumor resection.
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1 Video 1 Use of the insulated-tip knife in the case shown in Figure 6, for the dissection of the mucosal lesion from the underlying muscularis, in retroversion.
1 Video 2 The same same case as in video [V1] during the same session: here the dissection is beeing done in a prograde fashion.
T. Rösch, M. D.
Charité · Universitätsmedizin Berlin · Campus Virchow Klinikum · Medizinische Klinik
m.S. Hepatologie und Gastroenterologie · Zentrale Interdisciplinäre Endoskopie
Augustenburger Platz 1 · 13535 Berlin · Germany
Fax: +49-30-450-553902
Email: thomas.roesch@charite.de