- Email: [email protected]
Endoscopic mucosal resection using a partial transparent hood for lesions located tangentially to the endoscope
M Noda, N Kobayashi, H Kanemasa, et al.
Endoscopic mucosal resection using a partial transparent hood for lesions located tangentially to the endoscope Masao Noda, MD, Noriaki Kobayashi, MD, Hidetoshi Kanemasa, MD, Toshihito Tanahashi, MD, Naoki Wakabayashi, MD, Shoji Mitsufuji, MD, Tadashi Kodama, MD, Kei Kashima, MD Background: Numerous methods have been developed to resect early-stage gastric and esophageal cancers, but it is difficult to resect lesions viewed tangentially with the endoscope. Methods: We have designed and developed an original method of endoscopic mucosal resection using a partial transparent hood to treat difficult cases in which the Received March 29, 1999. For revision July 22, 1999. Accepted September 11, 1999. From the Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, Kyoto; and the Department of Gastroenterology, Otsu Municipal Hospital, Shiga, Japan. Reprint requests: Masao Noda, MD, Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan. Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 0 37/69/102949 338
GASTROINTESTINAL ENDOSCOPY
Endoscopic mucosal resection with partial transparent hood
lesions are located tangentially to the endoscope. The hood was attached on the right side of the endoscope and, after insertion into the stomach or the esophagus, was lightly pressed on the orad side of the lesion. Then the lesion was resected using grasping forceps and electrosurgical current snare. Results: The average diameter of specimens was 26 ± 8 mm in gastric lesions and 20 ± 3 mm in esophageal lesions, both 6 mm larger than those obtained by previous methods. Conclusion: This device and technique were extremely useful for mucosal resection of lesions located tangentially to the endoscope.
Endoscopic mucosal resection (EMR) of earlystage gastric or esophageal cancers is useful for local curative resection and also for maintaining the quality of life for patients. Over the past decade, developments in EMR and videoendoscopy have yielded good long-term results after EMR1-4 and have made EMR a standard treatment for earlystage gastric and esophageal cancers in Japan. The methods of endoscopic resection that have been developed thus far include the following: strip biopsy,5 endoscopic double-snare polypectomy (EDSP),6 VOLUME 51, NO. 3, 2000
Endoscopic mucosal resection with partial transparent hood
M Noda, N Kobayashi, H Kanemasa, et al.
Table 1. Summary Case
Age
Gender
Macroscopic appearance
Site of lesion
1 2 3 4 5 6 7 8 9 10
55 72 58 62 52 68 45 43 77 74
F M M M M M F M M M
Adenoma IIc Adenoma Adenoma Adenoma Adenoma IIc IIc IIc IIc
Lower body, posterior Middle body, posterior Middle body, posterior Antrum, posterior Antrum, posterior Lower body, posterior Esophagus Esophagus Esophagus Esophagus
endoscopic resection with local injection of I-ISE (ERHSE),7 endoscopic aspiration mucosectomy (EAM),8 endoscopic mucosal resection using a capfitted panendoscope (EMRC),9 endoscopic esophageal mucosal resection-tube (EEMR-tube),4 and endoscopic mucosal resection using a ligating device (EMRL).10 These methods can be separated into two major groups: the “lift-and-cut” method in which the lesion is resected by grasping and tracting it and the “suck-and-cut” method in which the lesion is aspirated to permit resection. In the former group, the lesion can now be resected more precisely and completely due to improvements in the grasping forceps. The latter method can now be performed more effectively due to a change to the tip-fitted hood that facilitates the manipulation or placement of the hood. However, the “lift-and-cut” method can be problematic for lesions located tangentially to the endoscope, and complete resection of large lesions has proven to be difficult with the “suck-and-cut” method. To overcome the deficiencies of these methods, we developed a partial transparent hood in cooperation with Olympus Optical Corporation Limited (Tokyo, Japan). The present study assesses the suitability of this experimental hood. PATIENTS AND METHODS Eight men and two women (mean age 61 ± 12 yr) underwent endoscopic mucosal resection with a partial transparent hood (ERPH) for a gastric or esophageal lesion between January 1995 and May 1999. There were 5 gastric adenomas (middle body 1, distal body 2, antrum 2), 1 early gastric cancer (middle body 1), and 4 early esophageal cancers. A 20 MHz catheter US probe (Olympus) was used to stage the cancer. All lesions were considered difficult to resect by conventional endoscopic methods because they were located at a tangent to the endoscope (Table 1). The study was approved by our institutional review board and informed written consent was obtained from parents or their families. In cooperation with the Olympus Corporation, the medical team designed a “1/3” type and a “1/4” type partial VOLUME 51, NO. 3, 2000
Size of specimen 19 35 20 36 20 25 21 16 22 19
× × × × × × × × × ×
17 mm 30 mm 17 mm 18 mm 15 mm 19 mm 13 mm 15 mm 7 mm 12 mm
Histology Adenoma Adenocarcinoma Adenoma Adenoma Adenoma Adenoma Squamous cell carcinoma Squamous cell carcinoma Squamous cell carcinoma Squamous cell carcinoma
Figure 1. A, A 1/3 type partial transparent hood fitted to the tip of a double channel videoendoscope. B, The V shaped grasping forceps (FG-42L Olympus) and snare (SD-9U-1 Olympus) are passed through the right and left channels, respectively. transparent hood. The 1/3 and 1/4 designs represented the proportion of the endoscope circumference that was hooded. We used a hood that could be attached to the doublechannel videoendoscope (GIF-2T200 Olympus) and which extended 11.5 mm from the tip of the endoscope as a basic model (external diameter 16.5 mm). The tip of the hood was made smooth to prevent injury during insertion. It was made from transparent polycarbonate to enable a frontal view of the lesion during resection of the gastric wall. The V-shaped grasping forceps (FG-42L Olympus) were used together with the 1/3 type hood. Wide grasping forceps (FG-13L or FG-49L Olympus), the standard model used at our institution, were used with the 1/4 type hood. A double-channel videoendoscope equipped with the 1/3 type partial transparent hood is shown in Figure 1. To resect of a lesion tangential to the endoscope, the hood was attached to the right side of the endoscope. The endoscope was inserted into the stomach or the esophagus under local pharyngeal anesthesia and was pressed lightly on the orad side of the tangential lesion to obtain a frontal view. Before resection, 4 point markings were made around the lesion with an electrosurgical needleknife when the lesion was not clearly demarcated. The submucosal layer was separated by injection of saline mixed with low-volume epinephrine (the same as for the conventional endoscopic mucosal resection method). Thereafter, the lesion was resected by the conventional GASTROINTESTINAL ENDOSCOPY
339
M Noda, N Kobayashi, H Kanemasa, et al.
Endoscopic mucosal resection with partial transparent hood
A
B
C
D
Figure 2. Schematic diagram of ERPH procedure. A, A double-channel endoscope equipped with the partial transparent hood on the right side is inserted into the stomach or esophagus just above a tumor which is located tangentially to the endoscope. B, A frontal view of the tumor is obtained by lightly pressing the hood against the orad side of the lesion. C, The tumor is retracted with a grasping forceps and resected electrosurgically with a snare. D, The resected specimen is captured and recovered with the grasping forceps. endoscopic mucosal resection technique using grasping forceps and an electrosurgical snare (Fig. 2). Endoscopic surveillance and histologic examination of biopsies were carried out every 3 months during the first year after ERPH, every 6 months in the second year, and annually thereafter. It is recommended that follow-up be continued for a period of no less than 3 years.
RESULTS A flat elevated lesion located on the posterior wall of the stomach is shown in Figure 3. In the esophagus, ERPH was performed after demarcation of the malignant lesions by staining with Lugol’s solution (Fig. 4). During the ERPH procedure, we were able to 340
GASTROINTESTINAL ENDOSCOPY
obtain a frontal view of all lesions and to easily grasp and retract them. The maximum diameter of resected mucosal tissue was 36 mm; the average diameter of specimens was 26 ± 8 mm for gastric lesions and 20 ± 3 mm for esophageal lesions, both of which were 6 mm larger than specimens obtained by the previous method. There was no congestion due to the mucosal aspiration, although mild injury due to the grasping forceps was found on specimens. In two cases, heat probe coagulation was carried out after histologic examination revealed tumor growth close to the resection margins. All 6 cases that had been followed for more than 2 years were in remisVOLUME 51, NO. 3, 2000
Endoscopic mucosal resection with partial transparent hood
M Noda, N Kobayashi, H Kanemasa, et al.
B
D
Figure 3. A, Endoscopic views of ERPH: flat elevated lesion located on the posterior wall of the stomach. B, Detail of lesion demonstrated by lightly pressing the hood against the orad aspect of the lesion. C, Lesion grasped and retracted vertically using the hood, and then resected using grasping forceps and electrosurgical snare. D, Partial transparent hood used to observe the ulcer after resection.
sion (no tumor cells identified in biopsies). In 1 case there was mild bleeding after resection that was stopped by standard hemostatic method. (Generally, a local injection of ethanol or clip placement is used.) There were no difficulties with insertion of the endoscope and no cases of perforation or injury to the esophago-pharyngeal region. DISCUSSION EMR is indicated for the following types of gastric cancer: (1) elevated type mucosal cancer less than 2 cm in size, (2) depressed type mucosal cancer without ulceration less than l cm in size, and (3) intestinal-type adenocarcinomas.2,11-13 By consensus, the indications for EMR of esophageal cancer include the following: (1) mucosal cancer within the proper mucosal layer invasion (i.e., confined to the mucosa without invasion of the muscularis mucosae), (2) size less than 2 cm, and (3) less than circumferential involvement.4,14,15 Developments in resection techVOLUME 51, NO. 3, 2000
niques have improved the ability to achieve a “local cure,” and good long-term results after EMR have been reported.1-4,16 However, in clinical practice, cases of local recurrence are sometimes encountered, particularly if the resection is incomplete. This often occurs with lesions on the posterior wall or the cardia of the stomach which are difficult to resect. If endoscopic rather than surgical treatment is to be used, the lesion must always be completely removed. Various resection methods have been developed, but it remains difficult to resect a lesion located tangentially to the endoscope by the “lift-and-cut” method, and it is difficult to resect large lesions by the “suck-and-cut” method. With ERPH, it was possible to endoscopically resect all tumors in a single session by obtaining a frontal view of the lesion located tangentially to the endoscope. We could also vary the diameter of the tissue to be resected and perform a resection to completely remove comparatively large lesions. Furthermore, it was possible to GASTROINTESTINAL ENDOSCOPY
341
M Noda, N Kobayashi, H Kanemasa, et al.
Endoscopic mucosal resection with partial transparent hood
C
Figure 4. ERPH of early stage esophageal cancer: A, The cancer is revealed as an unstained area after staining with Lugol’s solution. B, Frontal view of lesion obtained by pressing the hood against the orad side of the lesion. C, Resection of the lesion using grasping forceps and an electrosurgical snare. D, Observation of the resection site facilitated by use of the partial transparent hood.
obtain a frontal view of the ulcer after resection, which may be useful for hemostatic manipulation such as a local injection of ethanol or clip placement. Compared with the conventional transparent hood, the unique advantages of this method are that the view is less restricted and that it allows for easy manipulation of larger forceps. Placement of the partial hood was extremely easy and trouble free, although the hood had to be fitted to the right side of the endoscope. As a precaution, we reinforced the attachment site with vinyl tape, but no slipping or detachment occurred during the procedures. The manipulation of the forceps was restricted with the 1/2 type hood, but this was overcome by developing the 1/3 type and the 1/4 type hood. The length of the hood was not a hindrance, although it was necessary to keep an adequate distance between endoscope and lesion to resect the lesion precisely and completely. It was possible to insert the endoscope with the hood attached while 342
GASTROINTESTINAL ENDOSCOPY
simultaneously observing the esophago-pharyngeal region; injury to the esophago-pharyngeal region did not occur and there was no difficulty with insertion. The resected diameters of esophageal cancers were smaller than those of gastric lesions. It is somewhat difficult to manipulate the wide grasping forceps in the esophagus, where the amount of free space is less compared with the stomach. Thus, we used the wide grasping forceps (FG-13L Olympus) in only one case of an esophageal lesion, whereas it was used for all gastric lesions. If it were possible to maintain enough space in the esophagus or to develop a longer hood, more extensive resection might be possible. Because the average reported resected diameter for esophageal lesions is around 3 cm in the EMR method that uses an overtube (EEMR-tube),4 further improvement in ERPH may be necessary, particularly for resection of esophageal lesions. In conclusion, ERPH is extremely useful as a mucosal resection method for posterior wall lesions VOLUME 51, NO. 3, 2000
of the stomach, especially larger lesions, and is thought to be more useful than the conventional two-channel method for EMR of esophageal lesions. We are now studying the possibility of applying this method to rectal or sigmoid colon cancers located tangentially to the endoscope.
8.
9.
ACKNOWLEDGMENTS We acknowledge the support of Olympus Optical Corporation Limited, Tokyo, Japan, in supplying the partial transparent hood and for their technical assistance.
10.
REFERENCES
11.
1. Tada M, Murakami A, Karita M, Yanai H, Okita K. Endoscopic resection of early gastric cancer. Endoscopy 1993;25: 445-50. 2. Takekoshi T, Baba Y, Ota H, Kato Y, Yanagisawa A, Takagi K, et al. Endoscopic resection of early gastric carcinoma: results of a retrospective analysis of 308 cases. Endoscopy 1994;26:352-8. 3. Noda M, Kodama T, Atsumi M, Nakajima M, Sawai N, Kashima K, et al. Possibilities and limitations of endoscopic resection for early gastric cancer. Endoscopy 1997;29:361-5. 4. Makuuchi H. Endoscopic mucosal resection for early esophageal cancer: indication and techniques. Dig Endosc 1996;8:175-9. 5. Tada M, Murata M, Murakami F, Shimada M, Mizumachi M, Arima K, et al. Development of the strip-off biopsy [in Japanese with English abstract]. Gastroenterol Endosc 1984;26:833-9. 6. Takekoshi T, Fujii A, Takagi K, Baba Y, Kato H, Yanagisawa A. The indication for endoscopic double snare polypectomy of gastric lesions [in Japanese with English abstract]. Stomach Intestine 1988;23:387-98. 7. Hirao M, Masuda K, Asanuma T, Naka H, Noda K, Matsuura
VOLUME 51, NO. 3, 2000
12.
13.
14.
15.
16.
K, et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine. Gastrointest Endosc 1988;34:264-8. Torii A, Sakai M, Kajiyama T, Kishimoto H, Kin G, Inoue K, et al. Endoscopic aspiration mucosectomy as curative endoscopic surgery: analysis of 24 cases of early gastric cancer. Gastrointest Endosc 1995;42:475-9. Inoue H, Takeshita K, Hori H, Muraoka Y, Yoneshima H, Endo M. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc 1993;39:58-62. Akiyama M, Ota M, Nakajima H, Yamagata K, Munakata A. Endoscopic mucosal resection of gastric neoplasms using a ligating device. Gastrointest Endosc 1997;45:182-6. Iwashita A, Yamada Y, Arita M, Yao T, Takasaki J, Matsui T, et al. Indication of endoscopic curative resection for early gastric carcinoma from a pathologic point of view [in Japanese with English abstract]. Stomach Intestine 1991;26:265-74. Sano T, Kobori O, Muto T. Lymph node metastasis from early gastric cancer: endoscopic resection of turnout. Br J Surg 1992;79:241-4. Noda M. Characteristics of early gastric cancer accompanied by lymph node metastasis [in Japanese with English abstract]. Nippon Shokakibyo Gakkai Zasshi 1995;92 742-50. Momma K, Yoshida M, Yamada Y, Tadokoro Y, Tajima T, Iwasaki Y, et al. Endoscopic mucosectomy of early esophageal cancer [in Japanese with English abstract]. Stomach Intestine 1993;28:141-51. Inoue H. Endoscopic mucosal resection of early esophageal cancer: EMRT and EMRC techniques [in Japanese with English abstract]. Stomach Intestine 1993;28:161-9. Atsumi M, Kodama T, Uehira H, Kashima K. Surveillance after endoscopic resection and early diagnosis of local recurrence [in Japanese with English abstract]. Stomach Intestine 1993;28:1433-9.
GASTROINTESTINAL ENDOSCOPY
343
Endoscopic mucosal resection using a partial transparent hood for lesions located tangentially to the endoscope Masao Noda, MD, Noriaki Kobayashi, MD, Hidetoshi Kanemasa, MD, Toshihito Tanahashi, MD, Naoki Wakabayashi, MD, Shoji Mitsufuji, MD, Tadashi Kodama, MD, Kei Kashima, MD Background: Numerous methods have been developed to resect early-stage gastric and esophageal cancers, but it is difficult to resect lesions viewed tangentially with the endoscope. Methods: We have designed and developed an original method of endoscopic mucosal resection using a partial transparent hood to treat difficult cases in which the Received March 29, 1999. For revision July 22, 1999. Accepted September 11, 1999. From the Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, Kyoto; and the Department of Gastroenterology, Otsu Municipal Hospital, Shiga, Japan. Reprint requests: Masao Noda, MD, Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan. Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 0 37/69/102949 338
GASTROINTESTINAL ENDOSCOPY
Endoscopic mucosal resection with partial transparent hood
lesions are located tangentially to the endoscope. The hood was attached on the right side of the endoscope and, after insertion into the stomach or the esophagus, was lightly pressed on the orad side of the lesion. Then the lesion was resected using grasping forceps and electrosurgical current snare. Results: The average diameter of specimens was 26 ± 8 mm in gastric lesions and 20 ± 3 mm in esophageal lesions, both 6 mm larger than those obtained by previous methods. Conclusion: This device and technique were extremely useful for mucosal resection of lesions located tangentially to the endoscope.
Endoscopic mucosal resection (EMR) of earlystage gastric or esophageal cancers is useful for local curative resection and also for maintaining the quality of life for patients. Over the past decade, developments in EMR and videoendoscopy have yielded good long-term results after EMR1-4 and have made EMR a standard treatment for earlystage gastric and esophageal cancers in Japan. The methods of endoscopic resection that have been developed thus far include the following: strip biopsy,5 endoscopic double-snare polypectomy (EDSP),6 VOLUME 51, NO. 3, 2000
Endoscopic mucosal resection with partial transparent hood
M Noda, N Kobayashi, H Kanemasa, et al.
Table 1. Summary Case
Age
Gender
Macroscopic appearance
Site of lesion
1 2 3 4 5 6 7 8 9 10
55 72 58 62 52 68 45 43 77 74
F M M M M M F M M M
Adenoma IIc Adenoma Adenoma Adenoma Adenoma IIc IIc IIc IIc
Lower body, posterior Middle body, posterior Middle body, posterior Antrum, posterior Antrum, posterior Lower body, posterior Esophagus Esophagus Esophagus Esophagus
endoscopic resection with local injection of I-ISE (ERHSE),7 endoscopic aspiration mucosectomy (EAM),8 endoscopic mucosal resection using a capfitted panendoscope (EMRC),9 endoscopic esophageal mucosal resection-tube (EEMR-tube),4 and endoscopic mucosal resection using a ligating device (EMRL).10 These methods can be separated into two major groups: the “lift-and-cut” method in which the lesion is resected by grasping and tracting it and the “suck-and-cut” method in which the lesion is aspirated to permit resection. In the former group, the lesion can now be resected more precisely and completely due to improvements in the grasping forceps. The latter method can now be performed more effectively due to a change to the tip-fitted hood that facilitates the manipulation or placement of the hood. However, the “lift-and-cut” method can be problematic for lesions located tangentially to the endoscope, and complete resection of large lesions has proven to be difficult with the “suck-and-cut” method. To overcome the deficiencies of these methods, we developed a partial transparent hood in cooperation with Olympus Optical Corporation Limited (Tokyo, Japan). The present study assesses the suitability of this experimental hood. PATIENTS AND METHODS Eight men and two women (mean age 61 ± 12 yr) underwent endoscopic mucosal resection with a partial transparent hood (ERPH) for a gastric or esophageal lesion between January 1995 and May 1999. There were 5 gastric adenomas (middle body 1, distal body 2, antrum 2), 1 early gastric cancer (middle body 1), and 4 early esophageal cancers. A 20 MHz catheter US probe (Olympus) was used to stage the cancer. All lesions were considered difficult to resect by conventional endoscopic methods because they were located at a tangent to the endoscope (Table 1). The study was approved by our institutional review board and informed written consent was obtained from parents or their families. In cooperation with the Olympus Corporation, the medical team designed a “1/3” type and a “1/4” type partial VOLUME 51, NO. 3, 2000
Size of specimen 19 35 20 36 20 25 21 16 22 19
× × × × × × × × × ×
17 mm 30 mm 17 mm 18 mm 15 mm 19 mm 13 mm 15 mm 7 mm 12 mm
Histology Adenoma Adenocarcinoma Adenoma Adenoma Adenoma Adenoma Squamous cell carcinoma Squamous cell carcinoma Squamous cell carcinoma Squamous cell carcinoma
Figure 1. A, A 1/3 type partial transparent hood fitted to the tip of a double channel videoendoscope. B, The V shaped grasping forceps (FG-42L Olympus) and snare (SD-9U-1 Olympus) are passed through the right and left channels, respectively. transparent hood. The 1/3 and 1/4 designs represented the proportion of the endoscope circumference that was hooded. We used a hood that could be attached to the doublechannel videoendoscope (GIF-2T200 Olympus) and which extended 11.5 mm from the tip of the endoscope as a basic model (external diameter 16.5 mm). The tip of the hood was made smooth to prevent injury during insertion. It was made from transparent polycarbonate to enable a frontal view of the lesion during resection of the gastric wall. The V-shaped grasping forceps (FG-42L Olympus) were used together with the 1/3 type hood. Wide grasping forceps (FG-13L or FG-49L Olympus), the standard model used at our institution, were used with the 1/4 type hood. A double-channel videoendoscope equipped with the 1/3 type partial transparent hood is shown in Figure 1. To resect of a lesion tangential to the endoscope, the hood was attached to the right side of the endoscope. The endoscope was inserted into the stomach or the esophagus under local pharyngeal anesthesia and was pressed lightly on the orad side of the tangential lesion to obtain a frontal view. Before resection, 4 point markings were made around the lesion with an electrosurgical needleknife when the lesion was not clearly demarcated. The submucosal layer was separated by injection of saline mixed with low-volume epinephrine (the same as for the conventional endoscopic mucosal resection method). Thereafter, the lesion was resected by the conventional GASTROINTESTINAL ENDOSCOPY
339
M Noda, N Kobayashi, H Kanemasa, et al.
Endoscopic mucosal resection with partial transparent hood
A
B
C
D
Figure 2. Schematic diagram of ERPH procedure. A, A double-channel endoscope equipped with the partial transparent hood on the right side is inserted into the stomach or esophagus just above a tumor which is located tangentially to the endoscope. B, A frontal view of the tumor is obtained by lightly pressing the hood against the orad side of the lesion. C, The tumor is retracted with a grasping forceps and resected electrosurgically with a snare. D, The resected specimen is captured and recovered with the grasping forceps. endoscopic mucosal resection technique using grasping forceps and an electrosurgical snare (Fig. 2). Endoscopic surveillance and histologic examination of biopsies were carried out every 3 months during the first year after ERPH, every 6 months in the second year, and annually thereafter. It is recommended that follow-up be continued for a period of no less than 3 years.
RESULTS A flat elevated lesion located on the posterior wall of the stomach is shown in Figure 3. In the esophagus, ERPH was performed after demarcation of the malignant lesions by staining with Lugol’s solution (Fig. 4). During the ERPH procedure, we were able to 340
GASTROINTESTINAL ENDOSCOPY
obtain a frontal view of all lesions and to easily grasp and retract them. The maximum diameter of resected mucosal tissue was 36 mm; the average diameter of specimens was 26 ± 8 mm for gastric lesions and 20 ± 3 mm for esophageal lesions, both of which were 6 mm larger than specimens obtained by the previous method. There was no congestion due to the mucosal aspiration, although mild injury due to the grasping forceps was found on specimens. In two cases, heat probe coagulation was carried out after histologic examination revealed tumor growth close to the resection margins. All 6 cases that had been followed for more than 2 years were in remisVOLUME 51, NO. 3, 2000
Endoscopic mucosal resection with partial transparent hood
M Noda, N Kobayashi, H Kanemasa, et al.
B
D
Figure 3. A, Endoscopic views of ERPH: flat elevated lesion located on the posterior wall of the stomach. B, Detail of lesion demonstrated by lightly pressing the hood against the orad aspect of the lesion. C, Lesion grasped and retracted vertically using the hood, and then resected using grasping forceps and electrosurgical snare. D, Partial transparent hood used to observe the ulcer after resection.
sion (no tumor cells identified in biopsies). In 1 case there was mild bleeding after resection that was stopped by standard hemostatic method. (Generally, a local injection of ethanol or clip placement is used.) There were no difficulties with insertion of the endoscope and no cases of perforation or injury to the esophago-pharyngeal region. DISCUSSION EMR is indicated for the following types of gastric cancer: (1) elevated type mucosal cancer less than 2 cm in size, (2) depressed type mucosal cancer without ulceration less than l cm in size, and (3) intestinal-type adenocarcinomas.2,11-13 By consensus, the indications for EMR of esophageal cancer include the following: (1) mucosal cancer within the proper mucosal layer invasion (i.e., confined to the mucosa without invasion of the muscularis mucosae), (2) size less than 2 cm, and (3) less than circumferential involvement.4,14,15 Developments in resection techVOLUME 51, NO. 3, 2000
niques have improved the ability to achieve a “local cure,” and good long-term results after EMR have been reported.1-4,16 However, in clinical practice, cases of local recurrence are sometimes encountered, particularly if the resection is incomplete. This often occurs with lesions on the posterior wall or the cardia of the stomach which are difficult to resect. If endoscopic rather than surgical treatment is to be used, the lesion must always be completely removed. Various resection methods have been developed, but it remains difficult to resect a lesion located tangentially to the endoscope by the “lift-and-cut” method, and it is difficult to resect large lesions by the “suck-and-cut” method. With ERPH, it was possible to endoscopically resect all tumors in a single session by obtaining a frontal view of the lesion located tangentially to the endoscope. We could also vary the diameter of the tissue to be resected and perform a resection to completely remove comparatively large lesions. Furthermore, it was possible to GASTROINTESTINAL ENDOSCOPY
341
M Noda, N Kobayashi, H Kanemasa, et al.
Endoscopic mucosal resection with partial transparent hood
C
Figure 4. ERPH of early stage esophageal cancer: A, The cancer is revealed as an unstained area after staining with Lugol’s solution. B, Frontal view of lesion obtained by pressing the hood against the orad side of the lesion. C, Resection of the lesion using grasping forceps and an electrosurgical snare. D, Observation of the resection site facilitated by use of the partial transparent hood.
obtain a frontal view of the ulcer after resection, which may be useful for hemostatic manipulation such as a local injection of ethanol or clip placement. Compared with the conventional transparent hood, the unique advantages of this method are that the view is less restricted and that it allows for easy manipulation of larger forceps. Placement of the partial hood was extremely easy and trouble free, although the hood had to be fitted to the right side of the endoscope. As a precaution, we reinforced the attachment site with vinyl tape, but no slipping or detachment occurred during the procedures. The manipulation of the forceps was restricted with the 1/2 type hood, but this was overcome by developing the 1/3 type and the 1/4 type hood. The length of the hood was not a hindrance, although it was necessary to keep an adequate distance between endoscope and lesion to resect the lesion precisely and completely. It was possible to insert the endoscope with the hood attached while 342
GASTROINTESTINAL ENDOSCOPY
simultaneously observing the esophago-pharyngeal region; injury to the esophago-pharyngeal region did not occur and there was no difficulty with insertion. The resected diameters of esophageal cancers were smaller than those of gastric lesions. It is somewhat difficult to manipulate the wide grasping forceps in the esophagus, where the amount of free space is less compared with the stomach. Thus, we used the wide grasping forceps (FG-13L Olympus) in only one case of an esophageal lesion, whereas it was used for all gastric lesions. If it were possible to maintain enough space in the esophagus or to develop a longer hood, more extensive resection might be possible. Because the average reported resected diameter for esophageal lesions is around 3 cm in the EMR method that uses an overtube (EEMR-tube),4 further improvement in ERPH may be necessary, particularly for resection of esophageal lesions. In conclusion, ERPH is extremely useful as a mucosal resection method for posterior wall lesions VOLUME 51, NO. 3, 2000
of the stomach, especially larger lesions, and is thought to be more useful than the conventional two-channel method for EMR of esophageal lesions. We are now studying the possibility of applying this method to rectal or sigmoid colon cancers located tangentially to the endoscope.
8.
9.
ACKNOWLEDGMENTS We acknowledge the support of Olympus Optical Corporation Limited, Tokyo, Japan, in supplying the partial transparent hood and for their technical assistance.
10.
REFERENCES
11.
1. Tada M, Murakami A, Karita M, Yanai H, Okita K. Endoscopic resection of early gastric cancer. Endoscopy 1993;25: 445-50. 2. Takekoshi T, Baba Y, Ota H, Kato Y, Yanagisawa A, Takagi K, et al. Endoscopic resection of early gastric carcinoma: results of a retrospective analysis of 308 cases. Endoscopy 1994;26:352-8. 3. Noda M, Kodama T, Atsumi M, Nakajima M, Sawai N, Kashima K, et al. Possibilities and limitations of endoscopic resection for early gastric cancer. Endoscopy 1997;29:361-5. 4. Makuuchi H. Endoscopic mucosal resection for early esophageal cancer: indication and techniques. Dig Endosc 1996;8:175-9. 5. Tada M, Murata M, Murakami F, Shimada M, Mizumachi M, Arima K, et al. Development of the strip-off biopsy [in Japanese with English abstract]. Gastroenterol Endosc 1984;26:833-9. 6. Takekoshi T, Fujii A, Takagi K, Baba Y, Kato H, Yanagisawa A. The indication for endoscopic double snare polypectomy of gastric lesions [in Japanese with English abstract]. Stomach Intestine 1988;23:387-98. 7. Hirao M, Masuda K, Asanuma T, Naka H, Noda K, Matsuura
VOLUME 51, NO. 3, 2000
12.
13.
14.
15.
16.
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