Endoscopic Submucosal Resection (ESR) - a technique using novel devices for incision and resection of neoplastic lesions

Background and study aims: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established techniques for the treatment of superficial gastrointestinal neoplasia. Limitations of EMR are the low en bloc resection rates for larger lesions resulting in frequent recurrences. Major disadvantages of ESD are technical difficulty and long procedure times. Here, we evaluated technical feasibility and safety of newly designed devices to perform en bloc resection of lesions sized between ca. 20-40 mm. The method will be referred to as Endoscopic Submucosal Resection (ESR). Patients and methods: This case series included 93 lesions from different localizations (11x stomach, 25x colon, 57x rectum) with a median size of 29 (10-70) mm. ESR was carried out with two novel instruments for circumferential mucosal incision and for deep submucosal resection. Results: Resection by ESR was feasible in all cases. En bloc and R0 rates were insufficient when ESR was attempted without prior circumferential mucosal incision. However, en bloc and R0 resection rates were 70% and 63%, respectively when mucosal incision was done before application of the device for submucosal resection. We observed 3 complications (2 delayed bleedings, one microperforation) but no case of emergency surgery and no 30-day mortality. Conclusions: The series demonstrates feasibility and excellent safety of ESR using two novel devices for en bloc resection of early gastrointestinal neoplasia. The technique holds the promise of relative technical ease combined with high efficacy.

Endoscopic submucosal dissection: How to be more efficient?

Endoscopic submucosal dissection (ESD) allows an “en bloc” resection with safety margins (R0 resection) regardless of the size of the lesion. However, while R0 brings a real benefit for the patient, it is not considered sufficient by many experts to justify the technical difficulties and the longer procedure time compared to piecemeal mucosectomy. The aims of this review are to provide several technical and strategical tips to help you save time and become comfortable during ESD procedures. ESD is divided into several intertwined phases: injection, incision, access to the submucosae, and submucosal dissection itself. During injection there are some mistakes that should not be made: a superficial injection, or on the contrary, a too deep injection. A good needle and good injection technique are mandatory. Some techniques, such as repeated injection or prolonged lifting solution, can help maintain the lift. After this step, mucosal incision can be made, taking care to have a good margin to allow an R0 resection. Starting the mucosal incision from a small point allows calibration of the depth of the incision and then obtaining a nice incision. Trimming is also very important to widen submucosal access. Then comes the submucosal dissection itself. Strategies such as the tunnel strategy or the pocket creation method can help to facilitate dissection, but more importantly, traction systems have become unavoidable, especially in the stomach and colon. Most common complications are bleeding and perforation, and they usually can be managed endoscopically.

A case of esophageal granular cell tumor diagnosed by mucosal incision-assisted biopsy

For an esophageal submucosal mass suspicious of granular cell tumor (GCT) based on gross appearance and endoscopic ultrasound findings, a sufficient number of biopsy specimens is required for a definite diagnosis using immunohistochemical examination. When the specimen obtained by forceps biopsy is insufficient, endoscopic ultrasound-fine needle aspiration (EUS-FNA) is believed to be an useful alternative. However, it may be difficult to obtain an adequate amount of tumor material using EUS-FNA. Mucosal incision-assisted biopsy (MIAB) is a simple method that can collect larger amounts of specimens. This procedure is helpful for physicians who encounter the problem of obtaining an adequate amount of biopsy material from esophageal tumors suspicious for GCT. We present a case of esophageal GCT that was successfully diagnosed through MIAB.

245 A RETROSPECTIVE ANALYSIS OF ADVERSE EVENTS OF PERORAL ENDOSCOPIC MYOTOMY

Peroral endoscopic myotomy (POEM) has rapidly vindicated its position within the spectrum of achalasia treatment methods due to its excellent efficacy and safety. Nevertheless, POEM remains an invasive intervention which still carries risk of potential complications. The aim of our detailed analysis was to assess the perioperative and early postoperative adverse events in patients undergoing POEM at our institution. Methods We retrospectively evaluated the prospectively collected data from all consecutive patients who underwent POEM 12/2012–5/2018 at our institution and searched for periprocedural complications. Surgical classification Clavien Dindo (C-D) was used to assess the severity of adverse events. Results A total of 243 POEM procedures were performed. 73 procedures (30.0%) passed uneventfully while in 170 procedures (70.0%), 208 adverse events occurred. Minor AEs (C-D I,II) were as follows: allergic reaction to antibiotics (2/243; 0.8%), anaesthesia-related complications (14; 5.8%), pain requiring analgesics (158; 65%), fever (20; 8.2%), pneumonia (3; 1.2%) and irreversible loss of taste and smell (1; 0.4%). Major adverse events (CD III and more) included: post-POEM leak from mucosal incision requiring endoscopic clipping (5; 2.0%), pneumothorax (2; 0.8%), pleural effusion (1; 0.4%), scrotum emphysema (1; 0.4%) and death due to sudden cardiac arrest (1; 0.4%). Conclusion Minor POEM-related adverse events are rather common. Although being rare, severe complications, and even fatal, may still occur. Overall, POEM can be considered a safe procedure.

The Rostral Mucosa: The Door to Open and Close for Targeted Endoscopic Endonasal Approaches to the Clivus

BACKGROUND Extended endoscopic endonasal approaches (EEAs) have progressively widened the armamentarium of skull base surgeons. In order to reduce approach-related morbidity of EEAs and closure techniques, the development of alternative strategies that minimize the resection of normal tissue and alleviate the use of naso-septal flap (NSF) is needed. We report on a novel targeted approach to the clivus, with incision and closure of the mucosa of the rostrum, as the initial and final step of the approach. OBJECTIVE To present an alternative minimally invasive approach and reconstruction technique for selected clival chordomas. METHODS Three cases of clival chordomas illustrating this technique are provided, together with an operative video. RESULTS The mucosa of the rostrum is incised and elevated from the underlying bone, as first step of surgery. Following tumor resection with angled scope and instruments, the mucosa of the sphenoid sinus (SS) is removed and the tumor cavity and SS are filled with abdominal fat. The mucosal incision of the rostrum is then sutured. A hangman knot is prepared outside the nasal cavity and tightened after the first stitch and a running suture is performed. CONCLUSION We propose, in this preliminary report, a new targeted approach and reconstruction strategy, applying to EEAs the classic concept of skin incision and closure for transcranial approaches. With further development in the instrumentations and visualization tools, this technique may become a valuable minimally invasive endonasal approach for selected lesions.

Transoral per punctum excision of an impacted parotid duct stone of unfavorable direction: a case report

Background In the literature, the reported parotid duct stones that did not respond to the conservative measures are few. The present work reported and described the diagnosis and treatment of a case of impacted parotid duct stone that was surgically removed through minimally invasive transoral per punctum approach. Case presentation On examination of a 27-year-old male with left intermittent parotid swelling and pain for 1 year, a stone was palpated in the left buccal mucosa region near the orifice of the parotid duct. Ultrasonography (US) showed left Stensen’s duct distal stone. Under general anesthesia and oral intubation, the stone measuring about 1 cm in length was felt transversely located (directed at a right angle with the orifice of the duct). A small mucosal incision was done at the upper lateral part of the punctum; pus came out, and then the stone bulged from the orifice and was pushed outside. Recovery was event-less; postoperative paracetamol was sufficient to relieve pain, and the patient was discharged a few hours after the surgery. Conclusion The transoral per punctum excision of an impacted parotid duct stone appears to be a reliable minimally invasive effective and safe procedure. The unfavorable direction of the parotid duct stone might be a cause of failure of the conservative treatment for this stone.

Colorectal endoscopic submucosal dissection using the pocket-creation method with single clip traction: a feasibility study

Background and study aims The pocket-creation method (PCM) facilitates dissection of the central part of a tumor. We previously developed the PCM with clip traction (PCM-CT) to facilitate opening the mucosal pocket, which otherwise could become cumbersome. In the present study, we aimed to examine the feasibility of PCM-CT for colorectal endoscopic submucosal dissection (ESD). Patients and methods PCM-CT was performed on 30 patients with early colorectal tumors from October 2019 to April 2020. PCM-CT allows efficient opening of the mucosal pocket by using the PCM to dissect the center of the lesion and then apply traction with a single clip after making a circumferential mucosal incision. Results The median specimen major axis length, ESD time, ESD speed, and en bloc resection rate were 48 mm, 84 minutes, 20 mm2/min, and 100 % (30/30), respectively. The success rates for the traction clip and median single-clip-traction time were 100 % (30/30) and 1.5 minutes, respectively. Conclusions Colorectal ESD using PCM-CT is a simple and promising method.

DIAGNOSTIC ALTERNATIVES TO ENDOCOSPIC ULTRASOUND IN SUBEPITHELIAL LESIONS: A SYSTEMATIC REVIEW

Introduction: Subepithelial lesions are a challenge in clinical practice, often requiring a biopsy for a proper diagnosis. Currently, the gold standard is an endocospic ultrasound, which is rarely available. Objectives: Use a systematic review to check the effectiveness of the mucosal incision-assisted biopsy and assess whether it can be an alternative to endocospic ultrasound. Methods: The most relevant studies in the MedLine and SciELO databases were reviewed, and only randomized controlled clinical trials (RCT) and meta-analyses were considered. The search strategy used the following combinations of keywords: subepithelial lesion mucosal incision biopsy. The following terms were used to identify the study designs: clinical trials. Results: Seven articles that demonstrated the usefulness of the study technique and diagnostic efcacy were included in the scope of this review. This technique seems safe for biopsies. However, it is controversial for the resection of lesions. It has limitations, such as being more time-consuming. Conclusion: Mucosal incision-assisted biopsy can be considered useful in clinical practice and is still an effective technique and an alternative to endocospic ultrasound

Aging-Related Phenotypic Conversion of Medullary Microglia Enhances Intraoral Incisional Pain Sensitivity

Activated microglia involved in the development of orofacial pain hypersensitivity have two major polarization states. The aim of this study was to assess the involvement of the aging-related phenotypic conversion of medullary microglia in the enhancement of intraoral pain sensitivity using senescence-accelerated mice (SAM)-prone/8 (SAMP8) and SAM-resistant/1 (SAMR1) mice. Mechanical head-withdrawal threshold (MHWT) was measured for 21 days post palatal mucosal incision. The number of CD11c-immunoreactive (IR) cells [affective microglia (M1)] and CD163-IR cells [protective microglia (M2)], and tumor-necrosis-factor-α (TNF-α)-IR M1 and interleukin (IL)-10-IR M2 were analyzed via immunohistochemistry on days 3 and 11 following incision. The decrease in MHWT observed following incision was enhanced in SAMP8 mice. M1 levels and the number of TNF-α-IR M1 were increased on day 3 in SAMP8 mice compared with those in SAMR1 mice. On day 11, M1 and M2 activation was observed in both groups, whereas IL-10-IR M2 levels were attenuated in SAMP8 mice, and the number of TNF-α-IR M1 cells increased, compared to those in SAMR1 mice. These results suggest that the mechanical allodynia observed following intraoral injury is potentiated and sustained in SAMP8 mice due to enhancement of TNF-α signaling, M1 activation, and an attenuation of M2 activation accompanying IL-10 release.