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Tu1618 Esophageal Endoscopic Submucosal Dissection With a Newly Developped IT-Knife
Abstracts
number and dose of additional drugs, m-NLA-associated complications, history of alcohol consumption, and complications such as incidence rates of hypotension (blood pressure, ⬍ 90 mmHg), hypoxia (oxygen saturation, ⬉ 93%), and bradycardia (heart rate, ⬍ 50/min) were evaluated. Results: There were no cases of severe complications related to m-NLA. According to the ASA classification, patients were assigned to grade 1 (n ⫽ 26), 2 (n ⫽ 154), or 3 (n ⫽ 9). Mean sedation time was 99.1 ⫾ 59.9 min. Regarding additional drugs, 66 patients (34.9%) required midazolam alone, 115 (60.8%) required midazolam and flunitrazepam, and 8 (4.2%) required midazolam, flunitrazepam, and haloperidol. The mean dose of midazolam and pethidine was 12.4 and 108.3 mg, respectively. Hypotension, hypoxia, and bradycardia occurred in 45 (23.8%), 160 (84.7%), and 6 (3.2%) patients, respectively. Regarding alcohol consumption, patients with everyday/occasional drinking required a mean midazolam dose of 12.0/12.9 mg, respectively. The number of drugs necessary for full sedation was significantly higher in patients with everyday drinking than in patients with occasional drinking (p ⫽ 0.015). Conclusion: m-NLA with midazolam and pethidine is suggested to be useful for maintaining an appropriate sedation level, and is both feasible and safe in ESD for patients with SEC.
Tu1616 The Efficacy of Salvage Endoscopic Submucosal Dissection in Patients With Recurrent or Residual Tumor After Chemoradiotherapy for Esophageal Squamous Cell Carcinoma Manabu Takeuchi*1, Masaaki Kobayashi2, Satoru Hashimoto2, Kenichi Mizuno1, Yutaka Aoyagi1 1 Department of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan; 2Department of Endoscopy, Niigata University Medical and Dental Hospital, Niigata, Japan Background: Local recurrent or residual tumor after chemoradiotherapy (CRT) for esophageal squamous cell carcinoma remains an important problem. Although salvage esophagectomy after CRT is the only curative possibility, it carries a higher mortality and morbidity rate than primary surgery. If the carcinoma is a superficial lesion that is limited to the superficial submucosal layer, endoscopic mucosal resection (EMR) may be effective as salvage treatment. However, salvage EMR has problems: lifting is not easy because of submucosal fibrosis; it has a low complete en bloc resection rate; and a positive vertical margin can occur in submucosal invasive cancer. Aim and Methods: The aim of this study was to clarify the usefulness of salvage endoscopic submucosal dissection (ESD) for recurrent or residual superficial carcinoma without lymph node and distant metastases after CRT. Twenty-two lesions in 18 patients were resected with ESD from March 2005 to May 2011. Sixteen lesions were local recurrence or residual tumors at the primary site, and 6 were metachronous multiple cancers. All lesions were confirmed as intramucosal or submucosal tumors without lymph node or distant metastases on magnified endoscopy, endoscopic ultrasound (EUS), and computed tomography. The clinical outcomes for salvage ESD were analyzed retrospectively. Results: The mean sizes of resected specimens and tumors were 29.5 mm and 14.5 mm, respectively. The complete en bloc resection rate was 100% (22/22). There were no severe complications, such as perforation, associated with salvage ESD. At a median follow-up of 38 months (range 3 - 77 months) from salvage ESD, the local recurrence rate was 0% (0/22), and 12 patients (66.7%) were alive with no recurrence, but 3 patients (16.7%) had died from lymph node and/or distant metastases. The remaining patients (n ⫽ 3) had died from other diseases, including radiation pneumonia. Conclusion: If the locoregional failure lesion is limited to the submucosal layer with no metastases, ESD can be a salvage treatment for residual or recurrent superficial esophageal carcinoma after CRT as a safe and effective endoscopic therapy.
Tu1617 Long-Term Result of Photodynamic Therapy (PDT) As a Salvage Treatment for Patients With Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Squamous Cell Carcinoma (ESCC) Ken Hatogai*, Tomonori Yano, Takashi Kojima, Yusuke Yoda, Hironaga Satake, Atsushi Yagishita, Yasuhiro Oono, Hiroaki Ikematsu, Kazuhiro Kaneko, Atsushi Ohtsu Gastroenterology and GI Oncology, National Cancer Center Hospital East, Kashiwa, Japan Introduction: Local failure at the primary site after completion of chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (ESCC) is the major problem. While salvage esophagectomy is generally indicated for such patients, postoperative morbidity and mortality rates are higher than primary or planned esophagectomy. Aim & Method: The aim of this retrospective study was to clarify the long-term results in large amount of ESCC patients treated with salvage PDT. All patients had been treated with definitive CRT, consisting of more than 50 Gy external beam irradiation and concurrent chemotherapy. Local
failure lesions were diagnosed with conventional endoscopy and endoscopic ultrasound (EUS). The indication criteria of salvage PDT was as follows: (1) absence of clinical lymph node or distant organ metastasis after CRT, (2) tumor limited within T2 before PDT, (3) patient’s refusal of salvage esophagectomy or intolerance for surgery due to complications, (4) written informed consent. PDT was performed using excimer dye laser 48 and 72 hours after intravenous administration of Photofrin. Results A total of 103 consecutive patients (97 male, median age of 66 years) underwent salvage PDT between December 2002 and December 2009. According to UICC-2002 classification, the baseline clinical stage before CRT was as follows: T1/T2/T3/T4 in 13/17/55/18 patients, N0/1 in 45/58 patients, and stage I/II/III/IV in 10/39/47/7 patients, respectively. Prior to PDT, 64 patients were assessed as having uT1 lesion and 39 patients were as uT2 lesion; 73 patients had histologically proven local failure. 57 patients achieved complete response (CR rate; 55%, 95% CI 45-65) with salvage PDT. As complications, esophageal stenosis requiring balloon dilation occurred in 46 (45%). Esophageal perforation occurred in 5 patients (5%), and two of them died of aortic rupture in 28th day and in 63th day after PDT, respectively. Therefore, the treatment related death was found in 2% (2/103) in this study. With a median follow up period of 43 months after PDT, 32 of 57 CR patients with PDT did not develop any recurrence, whereas the remaining 25 had recurrent lesions (local in 12, lymph node in 8 and distant organ in 5 patients). The 3-year progression-free survival and overall survival rate of all 103 patients following PDT were 33% (95% CI, 23-42%) and 48% (95% CI, 37-59%), respectively. Conclusion: Salvage PDT could be one of the curative treatment options for patients with local failure limited within T2 without lymph node and distant metastasis after CRT for ESCC.
Tu1618 Esophageal Endoscopic Submucosal Dissection With a Newly Developped IT-Knife Masaki Tanaka*, Hiroyuki Ono, Naomi Kakushima, Kohei Takizawa, Madoka Takao, Toshitatsu Takao, Kinichi Hotta, Hiroyuki Matsubayashi, Yuichiro Yamaguchi Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Japan Introduction: Insulation-tipped knife (IT) is one of the most major electrosurgical devices used for endoscopic submucosal dissection (ESD) of gastric neoplasms. On the other hand it is less used in cases of esophageal neoplasm, because of the risk of perforation due to thinner wall and its difficulty in handling well in the narrow lumen. Therefore, devices without an insulation tip, Hook knife, Flex knife, or Flush knife are often selected as the main device for esophageal ESD. To compensate the weakness of IT, we developed a new IT-knife (new IT) to achieve safer and more efficient esophageal endoscopic submucosal dissection (EESD). Here we report the treatment outcomes of EESD with the new IT. Aims & Methods: The new IT has a smaller insulation tip and a small round diskshaped blade at the back side of the tip. Because of this small tip, we can easily insert the knife into the thin submucosal space. And the small round blade brings a better cutting ability than original IT knife. Furthermore, this small round disk induces a less sparking compared to IT-knife2, which leads to a reduction of the muscular damage. Between September 2009 and March 2011, we performed EESD with a new IT for 114 lesions in 100 patients at a single cancer referral center. We assessed the treatment outcomes of all cases. Secondly, we assessed the outcomes of novice endoscopist, who experienced less than 30 EESD cases. Results: Patients included 86 males and 14 females with a mean age of 67 years (range 43-85). The mean tumor size was 25.7mm (range 3-78). The mean procedure time of ESD (time from lesion marking to removing the lesion) was 51⫾33 minutes. The rate of en bloc resection was 100%. Concerning perioperative complication related to the procedure, perforation and mediastinal emphysema occurred in each 2 patients (1.8%). All patients were managed conservatively and no surgical intervention was needed. These data is comparable to the published data. (Mean tumor size; 22-32mm, Mean procedure time; 59-110min, En bloc resection rate; 95-100%, Complication rate; 3.9-10%)The treatment outcomes of novice doctors (Mean tumor size; 22mm, Mean procedure time; 52⫾27min, En bloc resection rate; 100%, Complication rate; 0%) were also comparable to the published data. Conclusion: The new IT knife provides an efficient esophageal ESD with an acceptable safety profile for novice and old pro alike.
Tu1619 Efficacy of Eradication of Non-Nodular Barrett’s After Mucosectomy in Patients With High-grade Dysplasia Using a CO2-Based Cryoablation System: An Initial Experience in a US Patient Cohort Rees G. Cameron, Kenneth F. Binmoeller, Janak N. Shah, Yusuke Hashimoto, Steve Kane, Yasser M. Bhat* Interventional Endoscopy Services (IES), California Pacific Medical Center, Foster City, CA Background: The endoscopic management of high grade dysplasia (HGD) or intramucosal carcinoma (CIS) in Barrett’s esophagus (BE) has evolved in recent
AB466 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
number and dose of additional drugs, m-NLA-associated complications, history of alcohol consumption, and complications such as incidence rates of hypotension (blood pressure, ⬍ 90 mmHg), hypoxia (oxygen saturation, ⬉ 93%), and bradycardia (heart rate, ⬍ 50/min) were evaluated. Results: There were no cases of severe complications related to m-NLA. According to the ASA classification, patients were assigned to grade 1 (n ⫽ 26), 2 (n ⫽ 154), or 3 (n ⫽ 9). Mean sedation time was 99.1 ⫾ 59.9 min. Regarding additional drugs, 66 patients (34.9%) required midazolam alone, 115 (60.8%) required midazolam and flunitrazepam, and 8 (4.2%) required midazolam, flunitrazepam, and haloperidol. The mean dose of midazolam and pethidine was 12.4 and 108.3 mg, respectively. Hypotension, hypoxia, and bradycardia occurred in 45 (23.8%), 160 (84.7%), and 6 (3.2%) patients, respectively. Regarding alcohol consumption, patients with everyday/occasional drinking required a mean midazolam dose of 12.0/12.9 mg, respectively. The number of drugs necessary for full sedation was significantly higher in patients with everyday drinking than in patients with occasional drinking (p ⫽ 0.015). Conclusion: m-NLA with midazolam and pethidine is suggested to be useful for maintaining an appropriate sedation level, and is both feasible and safe in ESD for patients with SEC.
Tu1616 The Efficacy of Salvage Endoscopic Submucosal Dissection in Patients With Recurrent or Residual Tumor After Chemoradiotherapy for Esophageal Squamous Cell Carcinoma Manabu Takeuchi*1, Masaaki Kobayashi2, Satoru Hashimoto2, Kenichi Mizuno1, Yutaka Aoyagi1 1 Department of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan; 2Department of Endoscopy, Niigata University Medical and Dental Hospital, Niigata, Japan Background: Local recurrent or residual tumor after chemoradiotherapy (CRT) for esophageal squamous cell carcinoma remains an important problem. Although salvage esophagectomy after CRT is the only curative possibility, it carries a higher mortality and morbidity rate than primary surgery. If the carcinoma is a superficial lesion that is limited to the superficial submucosal layer, endoscopic mucosal resection (EMR) may be effective as salvage treatment. However, salvage EMR has problems: lifting is not easy because of submucosal fibrosis; it has a low complete en bloc resection rate; and a positive vertical margin can occur in submucosal invasive cancer. Aim and Methods: The aim of this study was to clarify the usefulness of salvage endoscopic submucosal dissection (ESD) for recurrent or residual superficial carcinoma without lymph node and distant metastases after CRT. Twenty-two lesions in 18 patients were resected with ESD from March 2005 to May 2011. Sixteen lesions were local recurrence or residual tumors at the primary site, and 6 were metachronous multiple cancers. All lesions were confirmed as intramucosal or submucosal tumors without lymph node or distant metastases on magnified endoscopy, endoscopic ultrasound (EUS), and computed tomography. The clinical outcomes for salvage ESD were analyzed retrospectively. Results: The mean sizes of resected specimens and tumors were 29.5 mm and 14.5 mm, respectively. The complete en bloc resection rate was 100% (22/22). There were no severe complications, such as perforation, associated with salvage ESD. At a median follow-up of 38 months (range 3 - 77 months) from salvage ESD, the local recurrence rate was 0% (0/22), and 12 patients (66.7%) were alive with no recurrence, but 3 patients (16.7%) had died from lymph node and/or distant metastases. The remaining patients (n ⫽ 3) had died from other diseases, including radiation pneumonia. Conclusion: If the locoregional failure lesion is limited to the submucosal layer with no metastases, ESD can be a salvage treatment for residual or recurrent superficial esophageal carcinoma after CRT as a safe and effective endoscopic therapy.
Tu1617 Long-Term Result of Photodynamic Therapy (PDT) As a Salvage Treatment for Patients With Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Squamous Cell Carcinoma (ESCC) Ken Hatogai*, Tomonori Yano, Takashi Kojima, Yusuke Yoda, Hironaga Satake, Atsushi Yagishita, Yasuhiro Oono, Hiroaki Ikematsu, Kazuhiro Kaneko, Atsushi Ohtsu Gastroenterology and GI Oncology, National Cancer Center Hospital East, Kashiwa, Japan Introduction: Local failure at the primary site after completion of chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (ESCC) is the major problem. While salvage esophagectomy is generally indicated for such patients, postoperative morbidity and mortality rates are higher than primary or planned esophagectomy. Aim & Method: The aim of this retrospective study was to clarify the long-term results in large amount of ESCC patients treated with salvage PDT. All patients had been treated with definitive CRT, consisting of more than 50 Gy external beam irradiation and concurrent chemotherapy. Local
failure lesions were diagnosed with conventional endoscopy and endoscopic ultrasound (EUS). The indication criteria of salvage PDT was as follows: (1) absence of clinical lymph node or distant organ metastasis after CRT, (2) tumor limited within T2 before PDT, (3) patient’s refusal of salvage esophagectomy or intolerance for surgery due to complications, (4) written informed consent. PDT was performed using excimer dye laser 48 and 72 hours after intravenous administration of Photofrin. Results A total of 103 consecutive patients (97 male, median age of 66 years) underwent salvage PDT between December 2002 and December 2009. According to UICC-2002 classification, the baseline clinical stage before CRT was as follows: T1/T2/T3/T4 in 13/17/55/18 patients, N0/1 in 45/58 patients, and stage I/II/III/IV in 10/39/47/7 patients, respectively. Prior to PDT, 64 patients were assessed as having uT1 lesion and 39 patients were as uT2 lesion; 73 patients had histologically proven local failure. 57 patients achieved complete response (CR rate; 55%, 95% CI 45-65) with salvage PDT. As complications, esophageal stenosis requiring balloon dilation occurred in 46 (45%). Esophageal perforation occurred in 5 patients (5%), and two of them died of aortic rupture in 28th day and in 63th day after PDT, respectively. Therefore, the treatment related death was found in 2% (2/103) in this study. With a median follow up period of 43 months after PDT, 32 of 57 CR patients with PDT did not develop any recurrence, whereas the remaining 25 had recurrent lesions (local in 12, lymph node in 8 and distant organ in 5 patients). The 3-year progression-free survival and overall survival rate of all 103 patients following PDT were 33% (95% CI, 23-42%) and 48% (95% CI, 37-59%), respectively. Conclusion: Salvage PDT could be one of the curative treatment options for patients with local failure limited within T2 without lymph node and distant metastasis after CRT for ESCC.
Tu1618 Esophageal Endoscopic Submucosal Dissection With a Newly Developped IT-Knife Masaki Tanaka*, Hiroyuki Ono, Naomi Kakushima, Kohei Takizawa, Madoka Takao, Toshitatsu Takao, Kinichi Hotta, Hiroyuki Matsubayashi, Yuichiro Yamaguchi Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Japan Introduction: Insulation-tipped knife (IT) is one of the most major electrosurgical devices used for endoscopic submucosal dissection (ESD) of gastric neoplasms. On the other hand it is less used in cases of esophageal neoplasm, because of the risk of perforation due to thinner wall and its difficulty in handling well in the narrow lumen. Therefore, devices without an insulation tip, Hook knife, Flex knife, or Flush knife are often selected as the main device for esophageal ESD. To compensate the weakness of IT, we developed a new IT-knife (new IT) to achieve safer and more efficient esophageal endoscopic submucosal dissection (EESD). Here we report the treatment outcomes of EESD with the new IT. Aims & Methods: The new IT has a smaller insulation tip and a small round diskshaped blade at the back side of the tip. Because of this small tip, we can easily insert the knife into the thin submucosal space. And the small round blade brings a better cutting ability than original IT knife. Furthermore, this small round disk induces a less sparking compared to IT-knife2, which leads to a reduction of the muscular damage. Between September 2009 and March 2011, we performed EESD with a new IT for 114 lesions in 100 patients at a single cancer referral center. We assessed the treatment outcomes of all cases. Secondly, we assessed the outcomes of novice endoscopist, who experienced less than 30 EESD cases. Results: Patients included 86 males and 14 females with a mean age of 67 years (range 43-85). The mean tumor size was 25.7mm (range 3-78). The mean procedure time of ESD (time from lesion marking to removing the lesion) was 51⫾33 minutes. The rate of en bloc resection was 100%. Concerning perioperative complication related to the procedure, perforation and mediastinal emphysema occurred in each 2 patients (1.8%). All patients were managed conservatively and no surgical intervention was needed. These data is comparable to the published data. (Mean tumor size; 22-32mm, Mean procedure time; 59-110min, En bloc resection rate; 95-100%, Complication rate; 3.9-10%)The treatment outcomes of novice doctors (Mean tumor size; 22mm, Mean procedure time; 52⫾27min, En bloc resection rate; 100%, Complication rate; 0%) were also comparable to the published data. Conclusion: The new IT knife provides an efficient esophageal ESD with an acceptable safety profile for novice and old pro alike.
Tu1619 Efficacy of Eradication of Non-Nodular Barrett’s After Mucosectomy in Patients With High-grade Dysplasia Using a CO2-Based Cryoablation System: An Initial Experience in a US Patient Cohort Rees G. Cameron, Kenneth F. Binmoeller, Janak N. Shah, Yusuke Hashimoto, Steve Kane, Yasser M. Bhat* Interventional Endoscopy Services (IES), California Pacific Medical Center, Foster City, CA Background: The endoscopic management of high grade dysplasia (HGD) or intramucosal carcinoma (CIS) in Barrett’s esophagus (BE) has evolved in recent
AB466 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org