Figure
Abb. 12 9 Endoskopische Submukosadissektion am Ösophagus bei flächigem Barrett-Frühkarzinom . Ergebnis nach tubulärer Resektion sowie 3 Monate später unter temporärer Steroidstrikturprophylaxe . Nach außen gekehrtes tubuläres Resektat. (Mit freundl. Genehmigung von J. Hochberger)
Source publication
Endoscopic submucosal dissection (ESD) was developed in Japan but has now also become permanently established in various centers in Europe. ESD is an endoscopic en bloc mucosal resection technique for the treatment of early cancers with a diameter >1 cm and also superficial precancerous lesions, which could only be removed unsatisfactorily in sever...
Similar publications
Bile acids (BAs) are a group of water-soluble steroids formed during the ca- tabolism of cholesterol, and synthesised in the hepatocytes of the liver. The products, cholic acid (CA), and chenodeoxycholic acid (CDCA), are called pri- mary bile acids. Figure 1.1 shows an overview of the pathways involved in these reactions. These primary BAs are then...
Isolated involvement of the lower gastrointestinal tract with relative sparing of the oesophagus and the stomach is extremely rare following corrosive agent ingestion. We report a case of isolated full thickness jejunal necrosis following sulphuric acid cocktail ingestion. A 42 year old man presented with history of consuming 200 ml of sulphuric ac...
The spectrum of gluten related disorder might be much broader than currently believed. It is unknown why non-coeliac gluten sensitivity affects individuals at different ages. It is quite possible that triggering factors like infection might play an essential role in manifestation of this disorder. Similar to secondary lactose intolerance, gluten in...
Quality of life (QoL) is a multidimensional concept regarding self-assessment of patients’ situation. Quality of life has not been clearly defined up to date, although it is clear that it is a subjective self-assessment that to a significant extent is determined by individual needs, beliefs, values, attitudes, which are changing with time. Health-r...
Endoscopic resection of early gastric cancer is a well-established standard therapy in Japan, and is increasingly used in other countries. The development of endoscopic submucosal dissection (ESD) for early gastric cancer provides en bloc R0 specimen, regardless of size and/or location. On the other hand, for many years, conventional endoscopic muc...
Citations
... However, the superiority of ESD applies only for its use in the hand of an ESDexperienced endoscopic expert since ESD is complex and technically challenging. Therefore, ESD features a flat learning curve also for well-trained endoscopists and is associated with a relevant rate of adverse events, particularly perforations in up to 4-10% [12,37]. ...
Background and aims
With an external additional working channel (AWC) endoscopic mucosal resection (EMR) as well as endoscopic submucosal dissection (ESD) can be extended to techniques termed “EMR+” and “ESD+.” These novel techniques are systematically compared to EMR and ESD under the use of a double-channel endoscope (DC).
Methods
Our trial was conducted prospectively in a pre-clinical porcine animal model (EASIE-R simulator) with standardized gastric lesions measuring 3 or 4 cm.
Results
EMR+ and EMR DC showed both good results for 3 cm lesions with no adverse events and an en bloc resection rate of 73.33% (EMR+) and 60.00% (EMR DC, p = 0.70). They came to their limits in 4 cm lesions with muscularis damages of 20.00% (EMR+), 13.33% (EMR DC, p ≥ 0.99) and decreasing en bloc resection rates of 60.00% (EMR+) and 46.67% (EMR DC, p = 0.72).
ESD+ and ESD DC were both reliable concerning en bloc resection rates (100% in all groups) and adverse events (0.00% in 3 cm lesions, 12.50% muscularis damages in both ESD+ and ESD DC in 4 cm lesions).
Resection time was slightly shorter in all groups with the AWC compared to DC although only reaching significance in 3 cm ESD lesions (p < 0.05*).
Conclusions
With the AWC, a standard endoscope can easily be transformed to double-channel functionality. We could show that EMR+ and ESD+ are non-inferior to EMR and ESD under the use of a double-channel endoscope. Consequently, the AWC presents an affordable alternative to a double-channel endoscope for both EMR and ESD.
... Endoscopic mucosal resection (EMR) is widely performed and is an effective, minimally invasive endoscopic strategy for patients with large neoplastic mucosal based lesions. In the colon, saline-assisted snare resection of flat lesions (classic EMR) can be considered the established "gold-standard" technique [1,2]. ...
... But ESD is an advanced expert technique with a long learning curve, has a longer procedure time than EMR and a higher incidence of adverse events. One of the major complications is perforations, with an incidence up to 4 -10% [2,3]. ...
Background:
En-bloc resection of large, flat dysplastic mucosal lesions of the luminal GI tract can be challenging. In order to improve the efficacy of resection for lesions ≥2 cm and to optimize R0 resection rates of lesions suspected of harboring high-grade dysplasia or early adenocarcinoma, a novel grasp and snare EMR technique utilizing a novel over the scope additional accessory channel, termed EMR Plus (EMR+), was developed. The aim of this pilot study is to describe the early safety and efficacy data from the first in human clinical cases.
Methods:
A novel external over-the-scope additional working channel (AWC) (Ovesco, Tuebingen, Germany) was utilized for the EMR+ procedure, allowing a second endoscopic device to be used through the AWC while using otherwise standard endoscopic equipment. The EMR+ technique allows tissue retraction and a degree of triangulation during endoscopic resection. We performed EMR+ procedure in 6 patients between 02/2018-12/2018 for lesions in the upper and lower GI tract.
Results:
The EMR+ technique utilizing the AWC was performed successfully in 6 resection procedures of the upper and/or lower GI tract in 6 patients in 2 endoscopy centers. All resections were performed successfully with the EMR+ technique, all achieving an R0 resection. No severe adverse events occurred in any of the procedures.
Conclusions:
The EMR+ technique, utilizing an additional working channel, had an acceptable safety and efficacy profile in this preliminary study demonstrating it's first use in humans. This technique may allow an additional option to providers to remove complex, large mucosal-based lesions in the GI tract using standard endoscopic equipment and a novel AWC device.
Background and aimsA new external additional working channel (AWC) was recently introduced by which endoscopic submucosal dissection (ESD) can be converted to a technique termed “ESD+ ”. We aim to systematically evaluate this novel technique in flat gastric lesions and compare it to classical ESD.Methods
The study was prospectively conducted in a pre-clinical ex vivo animal model (EASIE-R simulator) with porcine stomachs. Prior to intervention, we set standardized lesions measuring 3 cm or 4 cm in antegrade as well as in retrograde positions.ResultsOverall, 64 procedures were performed by an experienced endoscopist. Both techniques were reliable and showed en bloc resection rates of 100%. Overall, ESD+ reduced time of procedure compared to ESD (24.5 vs. 32.5 min, p = 0.025*). Particularly, ESD+ was significantly faster in retrograde lesions with a median of 22.5 vs. 34.0 min in 3 cm retrograde lesions (p = 0.002*) and 34.5 vs. 41.0 min (p = 0.011*) in 4 cm retrograde lesions. There were 0 perforations with both techniques. In ESD+ , 1 muscularis damage occurred (3.13%) compared to 6 muscularis damages with ESD (18.75%, p = 0.045*).Conclusions
By its grasp-and-mobilize technique, ESD+ allows potentially faster and safer resections of flat gastric lesions compared to conventional ESD in an ex vivo porcine model. The potential advantages of ESD+ in terms of procedure time may be particularly relevant for difficult lesions in retrograde positions.
Introduction: To improve resection speed and to reach higher en bloc resection rates in lesions ≥ 2 cm, a novel grasp and snare EMR technique termed “EMR+”, accomplished by an additional working channel (AWC), was developed. Its use compared to endoscopic submucosal dissection (ESD) is evaluated for the first time.
Material and methods: We prospectively conducted a randomized pre-clinical ex-vivo pilot study in explanted porcine stomachs for the comparison of EMR + with classical ESD of mucosal-based lesions. Prior to intervention, we set flat lesions with a standardized size of 3 × 3 cm.
Results: The median time of procedure was significantly shorter in the EMR + group (median 10.5 min, range 4.4–24 min) than in the ESD group (median 32 min, range 14–61.6 min, p < .0001). The rate of en bloc resection was significantly lower in the EMR + group (38 % vs. 95 %) (p < .0001). Nevertheless, an improvement in the learning curve for EMR + was achieved after the first 12 procedures, with a subsequent en bloc resection rate of 100 %.
Conclusions: EMR + could improve the efficiency of mucosal resection procedures. Initial experience demonstrates a higher and satisfactory en bloc resection rate after going through the learning curve of EMR+.
Introduction Endoscopic submucosal dissection (ESD) is increasingly being used in the western world. Submucosal injectates are an essential tool for the ESD procedure. In this study, we evaluated a novel copolymer injectate (LiftUp, Ovesco, Tübingen Germany) in an established ESD model (EASIE-R) in comparison to existing submucosal injectables.
Materials and methods We conducted a prospective, randomized ex vivo study performing ESD with three injectates: LiftUp, hydroxyethyl starch (HAES 6 %) and normal saline solution (NaCl 0.9 %). A total of 60 artificial lesions, each 3 × 3 cm in size, were resected in an ex vivo porcine model, utilizing one of the three studied injectates (n = 20 ESDs per injectate). Study parameters were: en bloc resection rate, perforation rate, lifting property, time of injection, injectate volume, general ESD procedure time, and overall procedure time.
Results All 60 lesions were successfully resected using the standard ESD technique. LiftUp had no procedure related perforations, one perforation occurred in the HAES group, and two perforations in the NaCl group (P > 0.05). Furthermore, adequate lifting was achieved in 16/20 (80 %) using LiftUp, 6/20 (30 %) in the HAES group and 6/20 (30 %) in the NaCl group (P < 0.0002). En bloc resection was achieved in 19 (95 %) with LiftUp, in 20 (100 %) with HAES, and in 16 (80 %) with NaCl. General ESD procedure time and overall procedure time were not different among the three groups.
Conclusion LiftUp appears to be a safe alternative to established fluids for ESD. It had a significantly improved lifting effect and required significantly less injected volume compared to well-established lifting solutions.
The full-thickness resection device (FTRD) is a novel endoscopic device approved for the resection of colorectal lesions. This case-series describes the device and its use in high-risk patients with colorectal lesions and provides an overview of the potential indications in recently published data.
Between December 2014 and September 2015, 3 patients underwent endoscopic full thickness resection using the FTRD for colorectal lesions: 1 case for a T1 adenocarcinoma in the region of a surgical anastomosis after recto-sigmoidectomy, 1 case for a non-lifting colonic adenoma with low-grade dysplasia in an 89-year old patient and 1 for a recurrent adenoma with high-grade dysplasia in a young patient with ulcerative rectocolitis who was under immunosuppression after renal transplantation. Both technical and clinical success rates were achieved in all cases. The size of removed lesions ranged from 9 to 30 mm.
Overall, the most frequent indication in the literature has been for lifting or non-lifting adenoma, submucosal tumors, neuroendocrin tumors, incomplete endoscopic resection (R1) or T1 carcinoma.
Colorectal FTRD is a feasible technique for the treatment of colorectal lesions and represents a minimally invasive alternative for either surgical or conventional endoscopic resection strategies.
Die endoskopischen Resektionsverfahren prämaligner und maligner Läsionen im Ösophagus und Magen haben in den vergangenen 10 Jahren immer mehr an Bedeutung gewonnen. Die Detektion früher Neoplasien durch die diagnostische Endoskopie wurde erst möglich durch die Einführung der hochauflösenden Videoendoskopie mit ihren hilfreichen Zusatzfunktionen (digitale Chromoendoskopie, Zoom-Endoskopie usw.). Aufgrund der Limitationen der in Europa und der westlichen Welt etablierten endoskopischen Mukosaresektion (EMR) bestand der Wunsch nach En-bloc-Resektion größerer Areale mit gleichzeitiger Resektion eines ausreichenden lateralen und basalen Sicherheitsabstandes. Die endoskopische Submukosadissektion (ESD) ist eine in der asiatischen Welt entwickelte und dort seit mehr als 15 Jahren fest etablierte endoskopische Resektionstechnik, die die Grenzen der EMR überschreitet und die En-bloc-Resektion großflächiger oberflächlicher mukosaler Karzinome ermöglicht.
The goal in minimally-invasive surgery like NOTES (natural orifice transluminal endoscopic surgery), or single-port surgery, through one artificial incision, is to reduce the operative and post-operative stresses for the patients. Today's challenges for physicians during procedures are the missing mobility of the used flexible instruments inside the human body. Primarily the missing ability to manipulate tissue from different sides (triangulation of instruments) needs to be obtained. This article proposes the next prototype of our Multi Arm Snake-Like Robot and focuses on the kinematic development of the overtube body-frame for the flexible endoscope. We are following a new way developing a system for minimally- invasive surgery by using additive manufacturing methods like selective laser sintering (SLS). By using SLS it is feasible to create stiff structures with local flexure hinges monolithically that are custom made adapted for different patients and surgeries. To adapt our systems to different standard endoscopic equipment, procedures and patients we use a unique puzzle-clip mechanism. In the experiment the modularization of the system through the puzzle-clip system is shown. The used raw material PA 2200, a polyamide based thermoplastic polymer, is certificated as biocompatible according to DIN EN ISO 10993. This proves that the proposed Multi Arm Snake-Like SLS Robot system gets more advances towards the use during minimally-invasive procedures. And has a high chance to reach the final goal the clinical certification.
