endoscopic submucosal dissection of the stomach · endoscopic submucosal dissection of the stomach...
TRANSCRIPT
Endoscopic submucosal dissection
of the stomach
Professor, Department of Surgery, Institute of Digestive Disease
Director, CUHK Jockey Club Minimally Invasive Surgical Skills Center
Director, CUHK Chow Yuk Ho Technology Center for Innovative Medicine
Assistant Dean (Ext Affairs), Faculty of Medicine, The Chinese University of Hong Kong
Philip WY CHIU MD(CUHK), MBChB(CUHK), FRSCEd, FCSHK, FHKAM(Surg)
Gastric cancer: 2nd commonest
cancer worldwide 74% of the gastric cancers in the world occur in Asia!
Advanced Stage GI Cancers
• Usually treated by radical surgery followed with adjunctive chemotherapy (and / or) radiotherapy
• Grave prognosis with limited survival
Early gastric cancer Excellent prognosis
0
20
40
60
80
100
Italy Italy UK GermanyNetherlands Spain France USA Japan Japan Japan
5 y
r su
rviv
al
%
mucosa submucosa
Axon et al Lancet 1997
Early gastric cancers – difficult
to recognize under WLE
• High index of suspicion • Ample time for endoscopic examination • Image Enhanced Endoscopy (IEE) - NBI
Early gastric cancer Treatment options
EMR / ESD Laparoscopic Gastrectomy
Local treatment (Minimal risk of LN
metastasis
Loco-regional (high risk of LN
metastasis)
Risk of lymph node metastasis All cases of intramucosal cancers
Total LN % Diff. LN % Undiff LN %
< 10mm 357 4 1.1 257 0 0 100 4 4.0
< 20mm 767 4 0.5 455 0 0 312 4 1.3
< 30mm 927 10 1.1 518 0 0 409 10 2.4
> 31mm 965 47 4.9 417 7 1.7 548 40 7.3
Total 3016 65 2.2 1647 7 0.4 1369 58 4.2
Overall risk of LN metastasis for T1m: 2.2% Differentiated T1m: 0.4% Undifferentiated T1m: 4.2% Intramucosal EGC without ulcer: 0%
Gotoda et al. Gastric cancer 2000
Submucosal tumors – Risk of nodal metastasis
SM Total LN % Diff LN % Undiff LN %
< 10mm 99 8 8.1 70 6 8.6 29 2 6.9
< 20mm 437 56 12.8 266 32 12.0 171 24 14.0
< 30mm 567 106 18.7 344 56 16.3 223 50 22.4
> 31mm 743 130 17.5 411 92 22.4 332 38 11.4
Total 1846 300 16.3% 1091 186 17.0% 755 114 15.1%
Gotoda et al. Gastric cancer 2000
For submucosal carcinoma, overall risk of LN metastasis is > 15% Gastrectomy (LAG) should be recommended!
Advantages of Endoscopic Resection
• Local curative intent treatment
• Organ preservation – Function of the organ preserved
– Better quality of life
– Less post-gastrectomy syndromes
• Better postoperative outcome – Shorter hospital stay
– Early return of GI function
Chiu PW. GIE 2006
Endoscopic submucosal dissection
(ESD)
• En-bloc resection of early gastric cancer – Ensure clearance of resection margins
– Complete specimen for histopathology
Oda et al Dig Endosc 2005
EMR vs ESD for treatment of Early
Gastric Cancers EMR /
ESD No of patient
En-bloc resection Post ER bleeding
Perforation
Local re
curre
nce
Size of the EGC < 10mm > 10mm > 10mm
Watanabe et al
EMR 125 91.3% 63.6% 0% 3.0% 9.1%
ESD 120 92.9% 91.3% 0% 5.4 3.3%
Oka et al
EMR 825 61.9% 27.0% 7.6% 4.8% 4.4%
ESD 195 95.1% 94.4% 22.6% 8.7% 0%
Tanabe et al
EAM 359 52.1% 3.6% 3.3% 4.2%
ESD 421 92.9% 6.3% 3.3% 0.2%
ESD vs Gastrectomy for treatment
of EGC ESD (74) Gastrectomy (40) p
Median FU (months) 27.0 (1-65) 77.6 (1-180) < 0.001
Median OT Time 89.6 (45-360) 265 (150-360) < 0.001†
Blood loss (mls) 0.02 (0-1) 141.6 (0-1400) < 0.001†
Need of transfusion 1 (1.4%) 4 (10.0%) 0.056
Hospital stay 3 (2-10) 9.9 (6-26) < 0.001†
Complication 4 (5.4%) 13 (32.5%) < 0.001†
Reactionary bleeding 3 0
Anastomotic leak 0 0
Wound infection 0 3
ESD perforation 1 0
Intraabdominal collection 0 2
Chiu PW et al Surg Endosc 2012
Hospital Authority Hong Kong
Audit on Upper GI ESD 2010-2013
Teoh AY, Chiu PW, Chan FK et al
Total: 187
Guidelines on management of early GI cancers under Hospital Authority Head Office • Preclinical training workshop (with animal hands-
on) • Performance of ESD under proctorship
Difficulties in starting ESD
Teoh AY, Chiu PW, et al Surg Endosc 2009
Gastroenterologists (6) Surgeons (14) p
Mean size of specimen 2.67 +/- 1.17 2.69 +/- 11.49 0.695
Mean procedural time (min)
Gastric ESD 47.17 +/- 21.54 53.21 +/- 26.28 0.627
Esophageal ESD 25 +/- 7.07 34 +/- 5.48 0.124
Perforation 20 (62.5%)
Gastric 2 11 0.122
Esophageal 2 3 1
Procedure related mortality 1 1 0.521
Endoscopic multi-tasking platforms
EndoMaster
M.A.S.T.E.R.: Master And Slave Transluminal Endoscopic Robot Developed by Prof Lawrence Ho (National University Singapore) Prof Louis Phee (Singapore Nanyang Technological University)
Ho YK et al GIE 2010