Endoscopic submucosal tunnel dissection: the space between
2013; Elsevier BV; Volume: 78; Issue: 6 Linguagem: Inglês
10.1016/j.gie.2013.07.028
ISSN1097-6779
Autores Tópico(s)Gastroesophageal reflux and treatments
ResumoIn 2011 we witnessed the international emergence of endoscopic submucosal dissection (ESD).1Wang A.Y. The international emergence of endoscopic submucosal dissection for early gastric cancer.Gastrointest Endosc. 2011; 73: 928-931Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Since then, the number of ESD-trained endoscopists in the United States and in Western countries has increased to the point that a significant number of patients with GI neoplasia have been able to benefit from this innovative technique. Because of differences in referral patterns and the prevalence of gastric and other GI cancers in various countries, endoscopists who might not see many early gastric cancers have learned to perform ESD successfully in the colorectum and esophagus. With this experience, and with the continued rapprochement of GI endoscopy and surgery, ESD techniques have advanced and been used to perform peroral endoscopic myotomy (POEM) for patients with achalasia2Inoue H. Minami H. Kobayashi Y. et al.Peroral endoscopic myotomy (POEM) for esophageal achalasia.Endoscopy. 2010; 42: 265-271Crossref PubMed Scopus (1155) Google Scholar and to remove subepithelial lesions from the GI tract.3Inoue H. Ikeda H. Hosoya T. et al.Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia.Endoscopy. 2012; 44: 225-230Crossref PubMed Scopus (181) Google ScholarThe endoscopic creation of a submucosal tunnel is a technique that has been readily adopted by numerous endoscopists worldwide, as evidenced by the data presented in the International Per Oral Endoscopic Myotomy Survey4Stavropoulos S.N. Modayil R.J. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 108: 1293-1298Google Scholar and in a recent international prospective multicenter study.5von Renteln D. Fuchs K.H. Fockens P. et al.Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study.Gastroenterology. 2013; 145: 309-311Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar It is in this environment of endoscopic innovation, particularly in the area of ESD, that Arantes and his Brazilian and Japanese colleagues conducted their study,6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar which is featured in this month's issue of Gastrointestinal Endoscopy.Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar used a modified-ESD approach, which has been termed endoscopic submucosal tunnel dissection (ESTD),7Linghu E. Feng X. Wang X. et al.Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.Endoscopy. 2013; 45: 60-62PubMed Google Scholar to resect 25 dysplastic esophageal lesions from 23 patients. They reported an R0 (complete) resection rate of 84% and a final rate of curative resection in 80% of procedures. In their study, an R0 resection was defined as histologically complete tumor removal, with both lateral and deep margins free of neoplastic cells. A curative resection was defined as resected neoplasia restricted to the epithelium (m1) or lamina propria (m2) but not involving the muscularis mucosa (m3), with neoplasia-free vertical and radial margins and no lymphatic or vascular invasion. Adverse events were noted in 12% of procedures, with two cases of mediastinal and/or subcutaneous emphysema and one perforation at the distal incision site, which was repaired with endoclips, allowing ESTD to be finished. All patients with adverse events did well with conservative management and antibiotics.The technique used in this series differs from traditional ESD, which typically starts with circumferential incision to the submucosa and is then followed by submucosal dissection.The method used to perform ESTD in this series by Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar was to first make an incision down to the deep submucosa distal to the lesion, after which a similar deep-submucosal incision was made proximal to the lesion. Submucosal tunneling was performed from the proximal incision through to the distal incision. Once this was accomplished, submucosal dissection was extended laterally to the bilateral limits of the tumor. Finally, the remainder of the circumferential mucosal incision was carried out. By using a 1.5-mm–long, ball-tipped, Flush knife (Fujifilm Medical, Tokyo, Japan) to perform ESTD, these authors reported operating times, rates of en bloc and curative resection, and adverse events comparable to those reported in other series of esophageal ESD that used more conventional approaches.6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google ScholarThese ESTDs performed by Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar comprise the largest such series reported in the published literature. However, Linghu et al7Linghu E. Feng X. Wang X. et al.Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.Endoscopy. 2013; 45: 60-62PubMed Google Scholar had previously reported using this technique to perform wide mucosal resection of esophageal dysplasia in patients by using various ESD knives. These authors used ESTD to remove 5 large, esophageal lesions (all >2 cm in length, with a circumferential extent of more than one-third of the circumference, and with pathology ranging from high-grade dysplasia to sm1 cancer). These two publications from different continents support that the efficacy of esophageal ESTD is likely generalizable, when performed by experienced endoscopists.Potential beneficial factors for using ESTD for resection of early esophageal cancers (defined as high-grade dysplasia to T1 lesions8Enestvedt B.K. Ginsberg G.G. Advances in endoluminal therapy for esophageal cancer.Gastrointest Endosc Clin N Am. 2013; 23: 17-39Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar) include (1) the ability to perform blunt submucosal dissection by using the transparent cap, (2) that submucosal injection solutions are better retained in the submucosa because of elimination of the initial circumferential incision, and (3) that the gas cushion caused by insufflation might increase the distance between the mucosa and muscularis propria, contributing to blunt dissection.7Linghu E. Feng X. Wang X. et al.Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.Endoscopy. 2013; 45: 60-62PubMed Google Scholar Whereas Linghu et al7Linghu E. Feng X. Wang X. et al.Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.Endoscopy. 2013; 45: 60-62PubMed Google Scholar used carbon dioxide insufflation (in patients receiving anesthesia and positive-pressure ventilation) without any insufflation-related adverse events, Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar used room-air insufflation but reported two cases of mediastinal and subcutaneous emphysema.Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar state that this ESTD technique offers a standardized approach that may facilitate the ESD learning process for Western endoscopists, and it can be applied to either small or large lesions. Although esophageal ESD is more difficult than gastric or rectal ESD, mainly because of the confined space and the thinner esophageal wall, it is not known whether ESTD is an easier technique to learn and master than conventional ESD. In fact, Dr Arantes, who performed all of these ESTD cases, first underwent proctored, intensive clinical training and several sessions of hands-on practice in animals, followed by gaining experience as a first assistant in human ESTD procedures. Then, he performed 25 unsupervised traditional gastric and rectal ESD procedures—all before performing esophageal ESTD in a patient. Dr Arante's preparation and training is laudable, and it underscores my personal belief that ESTD is likely to be easily learned by an endoscopist already skilled in conventional ESD, but it remains unclear how easy ESTD would be to learn without some prior ESD experience. However, it appears that the cognitive and technical skills required in creating and using the submucosal tunnel for ESTD overlap with the skill set required to perform POEM and subepithelial tumor resection; as such, ESTD might be readily adopted by endoscopists already trained in these related procedures.Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar make the point that ESTD can be used to resect smaller lesions, but, as is the case with conventional ESD, for dysplastic esophageal lesions and early cancers <1.5 cm in size, EMR is likely to be easier than ESD and offers comparable rates of oncologic cure.8Enestvedt B.K. Ginsberg G.G. Advances in endoluminal therapy for esophageal cancer.Gastrointest Endosc Clin N Am. 2013; 23: 17-39Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 9Ishihara R. Iishi H. Uedo N. et al.Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan.Gastrointest Endosc. 2008; 68: 1066-1072Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar Furthermore, a recent retrospective study published in this journal demonstrated that for superficial T1a esophageal adenocarcinomas measuring 2 cm in length, with a circumferential extent of more than one-third of the circumference, and with pathology ranging from high-grade dysplasia to sm1 cancer). These two publications from different continents support that the efficacy of esophageal ESTD is likely generalizable, when performed by experienced endoscopists. Potential beneficial factors for using ESTD for resection of early esophageal cancers (defined as high-grade dysplasia to T1 lesions8Enestvedt B.K. Ginsberg G.G. Advances in endoluminal therapy for esophageal cancer.Gastrointest Endosc Clin N Am. 2013; 23: 17-39Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar) include (1) the ability to perform blunt submucosal dissection by using the transparent cap, (2) that submucosal injection solutions are better retained in the submucosa because of elimination of the initial circumferential incision, and (3) that the gas cushion caused by insufflation might increase the distance between the mucosa and muscularis propria, contributing to blunt dissection.7Linghu E. Feng X. Wang X. et al.Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.Endoscopy. 2013; 45: 60-62PubMed Google Scholar Whereas Linghu et al7Linghu E. Feng X. Wang X. et al.Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.Endoscopy. 2013; 45: 60-62PubMed Google Scholar used carbon dioxide insufflation (in patients receiving anesthesia and positive-pressure ventilation) without any insufflation-related adverse events, Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar used room-air insufflation but reported two cases of mediastinal and subcutaneous emphysema. Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar state that this ESTD technique offers a standardized approach that may facilitate the ESD learning process for Western endoscopists, and it can be applied to either small or large lesions. Although esophageal ESD is more difficult than gastric or rectal ESD, mainly because of the confined space and the thinner esophageal wall, it is not known whether ESTD is an easier technique to learn and master than conventional ESD. In fact, Dr Arantes, who performed all of these ESTD cases, first underwent proctored, intensive clinical training and several sessions of hands-on practice in animals, followed by gaining experience as a first assistant in human ESTD procedures. Then, he performed 25 unsupervised traditional gastric and rectal ESD procedures—all before performing esophageal ESTD in a patient. Dr Arante's preparation and training is laudable, and it underscores my personal belief that ESTD is likely to be easily learned by an endoscopist already skilled in conventional ESD, but it remains unclear how easy ESTD would be to learn without some prior ESD experience. However, it appears that the cognitive and technical skills required in creating and using the submucosal tunnel for ESTD overlap with the skill set required to perform POEM and subepithelial tumor resection; as such, ESTD might be readily adopted by endoscopists already trained in these related procedures. Arantes et al6Arantes V. Albuquerque W. Dias C.A.F. et al.Standardized endoscopic submucosal tunnel dissection for management or early esophageal tumors.Gastrointest Endosc. 2013; 78: 946-952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar make the point that ESTD can be used to resect smaller lesions, but, as is the case with conventional ESD, for dysplastic esophageal lesions and early cancers <1.5 cm in size, EMR is likely to be easier than ESD and offers comparable rates of oncologic cure.8Enestvedt B.K. Ginsberg G.G. Advances in endoluminal therapy for esophageal cancer.Gastrointest Endosc Clin N Am. 2013; 23: 17-39Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 9Ishihara R. Iishi H. Uedo N. et al.Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan.Gastrointest Endosc. 2008; 68: 1066-1072Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar Furthermore, a recent retrospective study published in this journal demonstrated that for superficial T1a esophageal adenocarcinomas measuring <20 mm in size, EMR followed by ablative therapy (radiofrequency ablation, cryotherapy, or photodynamic therapy) offered complete remission from cancer in 96% of patients at 23 months mean follow-up.10Saligram S. Chennat J. Hu H. et al.Endotherapy for superficial adenocarcinoma of the esophagus: an American experience.Gastrointest Endosc. 2013; 77: 872-876Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Although these authors believe that ESTD offers a way to standardize the approach to esophageal ESD, competing technologies, new devices, and the realities of medical cost containment will enable and necessitate that GI endoscopists perform these procedures in the most effective and efficient way possible. In my opinion, esophageal ESTD is a useful technique for those with the proper skill set and experience, but the final “answer” to esophageal ESD may be yet to come. A recent, randomized study demonstrated significantly shorter submucosal dissection time for esophageal ESD by using a knife with an insulating shaft and cutting wire (Mucosectom; Pentax Medical, Tokyo, Japan), as compared with a Flush Knife (Fujifilm Medical Systems, Stamford, CT).11Kanzaki H. Ishihara R. Ohta T. et al.Randomized study of two endo-knives for endoscopic submucosal dissection of esophageal cancer.Am J Gastroenterol. 2013; 108: 1293-1298Crossref PubMed Scopus (21) Google Scholar Another study demonstrated significantly shorter procedure times and lower rate of adverse events by using a scissors-type device called the Stag-beetle knife (Sumitomo Bakelite, Tokyo, Japan), as compared with a Hook knife (Olympus, Tokyo, Japan).12Fujinami H, Hosokawa A, Ogawa K, et al. Endoscopic submucosal dissection for superficial esophageal neoplasms using the stag beetle knife. Dis Esophagus. Epub 2013 Feb 26.Google Scholar Last, a recent abstract reported use of a novel submucosal lifting gel that was injected into the esophageal submucosa during POEM in a porcine model, and this gel was able to be pushed in a piston-like fashion to allow “auto-dissection” of the submucosa. Furthermore, the gel appeared to have a tamponade effect, thereby minimizing bleeding.13Shinoura S. Samarasena J.B. Choi K. et al.Peroral endoscopic myotomy (POEM) with a novel submucosal lifting gel—Can we throw the knife away?.Gastrointest Endosc. 2013; 77 ([abstract]) (AB113)Abstract Full Text Full Text PDF Google Scholar At this time, I see ESTD as a variation of conventional ESD, which will be performed by a few skilled endoscopists with specialized training. In my opinion, improvements solely in the technique of performing ESD are unlikely to make this procedure more accessible to more endoscopists. New devices, such as the aforementioned endoscopic knives and scissors, are welcome advances but will not reduce procedural complexity or improve the learning curve so dramatically that experienced endoscopists with only minimal training in ESD will be able to adopt this technique. In 2013, we are still waiting for a beneficial and sufficiently disruptive technology that will make performing ESD—in the esophagus or elsewhere—easier to learn and perform, more efficient, and safer, so that most experienced endoscopists might have a reasonable chance at performing this procedure as part of routine practice. Although the novel submucosal lifting gel holds promise as a technology that might change significantly how ESD or ESTD is performed, 510(k) premarketing evaluation and clearance by the U.S. Food and Drug Administration and studies about its safety and efficacy in patients are required. Despite the need for continued innovation and research in ESD, we, as GI endoscopists—and our patients—are fortunate to practice in a time in which we have the tools, techniques, and expertise to bridge the space between medicine and surgery and to endoscopically work in the space between the mucosa and the muscularis propria. The essence of these concepts, as they relate to ESD and ESTD, is probably best captured in the words of a few men from Charlottesville, Virginia, who are not endoscopists or former U.S. presidents:The space betweenThe tears we cry...Is the laughter that keeps us coming back for more“The space between,” Everyday, the Dave Matthews Band, 2001. DisclosureThe author disclosed no financial relationships relevant to this publication. The author disclosed no financial relationships relevant to this publication. Standardized endoscopic submucosal tunnel dissection for management of early esophageal tumors (with video)Gastrointestinal EndoscopyVol. 78Issue 6PreviewEndoscopic submucosal dissection (ESD) was first developed to remove en bloc early gastric neoplasms.1,2 Later, this technique was proposed for the management of esophageal and colorectal superficial tumors, and currently ESD is performed routinely in Asia.3 ESD is indicated for esophageal cancer with no or minimal risk of lymph node metastasis. When the lesions are classified according to the depth of invasion as intraepithelial carcinoma (M1), restricted within the proper mucosal layer (M2), adjacent to or invading but not beyond the muscularis mucosa (M3), invading the submucosal (SM) layer to a depth of one third (SM1) or more than one third (SM2 and SM3) of the layer thickness, then the incidence of lymph node metastasis was reported to be 0%, 0% to 5.6%, 8% to 18%, 11% to 53%, and 30% to 54%, respectively. Full-Text PDF
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