Efficacy and Safety of Endoscopic Submucosal Dissection for Tumors of the Esophagogastric Junction

Background and Study Aims: The esophagogastric junction (EGJ) has been considered a difficult location for endoscopic treatment of tumors, due to its narrow lumen and sharp angle. Endoscopic submucosal dissection (ESD) is a method of endoscopic resection, capable of removing large tumors in an en bloc fashion. The aim of this study was to evaluate the efficacy and safety of ESD for EGJ tumors.
Patients and Methods: For 30 lesions of EGJ tumors treated by ESD, the size of the lesions and resected specimens, the en bloc resection rate, complications, and local recurrence were assessed.
Results: The average maximum diameters of the lesions and resected specimens were 22.4 mm and 40.6 mm respectively. The complete en bloc resection (R0) rate was 97 % (29/30). Histological evaluation of the resected specimens revealed five cases of angiolymphatic invasion and five cases of submucosal invasion deeper than 500 μm. Perforation occurred in one case but was safely managed by rotatable clips and administration of antibiotics for 3 days. Local recurrence was not observed in any patient during follow-up (mean 14.6 months, range 6 - 31 months).
Conclusions: ESD can be safely performed for EGJ tumors, with a high en bloc resection rate. For lesions with no apparent submucosal invasion findings, ESD is a curative and diagnostic treatment option that may be considered before open surgery.

References

• 1 Hirao M, Masuda K, Asanuma T. et al . Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine.  Gastrointest Endosc. 1988;  34 264-269
• 2 Yahagi N, Fujishiro M, Kakushima N. et al . Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type).  Dig Endosc. 2004;  16 34-38
• 3 Yahagi N, Fujishiro M, Iguchi M. et al . Theoretical and technical requirements to expand EMR indications.  Dig Endos. 2003;  15 (Suppl) S19-S21
• 4 Yahagi N, Fujishiro M, Kakushima N. et al . Merits and demerits of endoscopic submucosal dissection using a Flex Knife [In Japanese with English abstract].  Stomach Intestine (Tokyo). 2004;  39 39-43
• 5 Yahagi N, Fujishiro M, Imagawa A. et al . Endoscopic submucosal dissection for the reliable en bloc resection of colorectal mucosal tumors.  Dig Endosc. 2004;  16 (Suppl) S89-S92
• 6 Siewert J R, Stein H J. Carcinoma of the cardia: carcinoma of the gastroesophageal junction - classification, pathology and extent of resection.  Dis Esophagus. 1996;  9 173-182
• 7 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon . .  Gastrointest Endosc. 2003;  58 S3-S43
• 8 Fujishiro M, Yahagi N, Kashimura K. et al . Different mixtures of sodium hyaluronate and their ability to create submucosal fluid cushions for endoscopic mucosal resection.  Endoscopy. 2004;  36 584-589
• 9 Fujishiro M, Yahagi N, Kashimura K. et al . Comparison of various submucosal injection solutions for maintaining mucosal elevation during endoscopic mucosal resection.  Endoscopy. 2004;  36 579-583
• 10 Barr H, Shepherd N A, Dix A. et al . Eradication of high-grade dysplasia in columnar-lined (Barrett’s) oesophagus by photodynamic therapy with endogenously generated protoporphyrin 9.  Lancet. 1996;  348 584-585
• 11 Eguchi T, Gotoda T, Oda I. et al . Is endoscopic one-piece mucosal resection essential for early gastric cancer?.  Dig Endosc. 2003;  15 113-116
• 12 Gotoda T, Ono H, Oda I. et al . The importance of histological evaluation and the necessity of one-piece resection for endoscopic gastric mucosal resection [In Japanese with English abstract].  Stomach Intestine (Tokyo). 2002;  37 1145-1154
• 13 Japanese Gastric Cancer Association .Guidelines for gastric cancer treatment. Tokyo; Kanehara-shuppan 2001
• 14 Miyamoto S, Muto M, Hamamoto Y. et al . A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms.  Gastrointest Endosc. 2002;  55 576-581
• 15 Yamamoto H, Kawata H, Sunada K. et al . Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate.  Gastrointest Endosc. 2002;  56 507-512
• 16 Oyama T, Miyata Y, Tomori A. et al . Endoscopic mucosal resection for esophago-gastric junctional cancer [In Japanese with English abstract].  Stomach Intestine (Tokyo). 2001;  36 683-688
• 17 Oda I, Gotoda T, Hamanaka H. et al . Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series.  Dig Endosc. 2005;  17 54-58
• 18 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 19 Ookuwa M, Hosokawa K, Boku N. et al . New endoscopic treatment for intramucosal tumors using an insulated-tip diathermic knife.  Endoscopy. 2001;  33 221-226