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Esd
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- 2. BACKGROUND Endoscopic removalof tumors was first described in the era of rigid sigmoidoscope in 1955 Saline injection in submucosal space as safety cushion for elevation of lesion was described in 1973 EMR- endoscopic mucosal resection is the precursor of endoscopic submucosal dissection(ESD) Endoscopic submucosal dissection was described first in 1988 by Hirao et al from Japan
- 4. PROCEDURE PRINCIPLES Markingof the perimeter of the lesion Lifting agent injection into the submucosa around the perimeter of the lesion Incising the mucosa and then cutting circumferentially around the lesion Dissection along with hemostatis Attempting en-block removal of the lesion
- 5. DEVICES FORTHE ESD Dyes Knives Injection agents and delivery devices Hemostatic forceps and other devices Tissue retractors Endoscopes Electrosurgical unit
- 6. DYES Colorants suchas indigo carmine, methylene blue and Lugols iodine are used Used for initial evaluation of marking lesion of interest. NBI can be used instead but no comparative studies available.
- 7. KNIVES The earliestdedicated ESD device simply added a ceramic tip to an existing needle-knife to prevent in advertent deep dissection and there by perforation Various varieties of knives are available with no randomized studies to prove superiority of one type over another Most of these are compatible with the 2.8mm channel in the endoscope
- 8. IT KNIFE (INSULATEDTIP) IT - It has 2.2mm ceramic ball at end of 4mm cutting knife IT2 triangular electrode IT nano - 1.7 ball, 3.5mm cutting knife Circumferential incision and submucosal dissection
- 9. 2. HOOK KNIFE Hook –Tip bent at 90 degree, L shaped Length 4.5mm, hook 1.3mm Knife length and direction both adjustable Allow hooking and retraction of tissue Can be used for pre incision marking This can used any where, particularly when fibrotic tissue is present.
- 10. DUALKNIFE AND FLEXKNIFE DualKnife –Very small dome shaped non insulated tip, 2mm in length For marking full retraction in the sheath –leaves only 0.3mm tip out of the catheter. Full extension for cutting and dissection FlexKnife – Braided 0.8mm diameter cutting knife with looped tip, variably extensible.
- 11. HYBRIDKNIFE Developed byERBE electrosurgicals. Has a central capillary within the cutting knife provides ultrafine 120 micron water jet. This single device can perform all the phases of ESD alone. Submucosal elevation by water jet, marking, cutting and dissection. Has 3 tip configurations, I type,T type(disc) and O type(insulated dome)
- 12. HEMOSTATIC FORCEPS Monopolarand bipolar forceps Use to treat bleed with coaptive(mutually fitting) thermocoagulation Coagrasper is monopolar hemostatic forcep, serrated jaws Opening width 5mm
- 13. TISSUE RETRACTORS Transparentcap applied to the tip of endoscope. Servers to keep the resected flap of the mucosa off of the endoscope lens prevent red out Disposable with various size and shapes available. Some caps have irrigation port Newer caps from Olympus has retractor attached to it - Endolifter, since cap retraction is not sufficient enough For less affording setups external grasping forceps can be used.
- 14. INJECTION AGENTS Inj.agents are first injected around the perimeter of the lesion to provide a safety margin and later injected below the lesion during dissection phase Goals of an ideal agent Safety Low cost Provision of long lasting cushion Normal saline – Safe, low cost not long lasting Western endoscopists – Sod. Hyaluronate(0.4%) – safe, long lasting but expensive
- 15. Another alternativeis 0.4% hydroxymethyl cellulose - cheaper Injectate is colored with indigo carmine to help differentiate tissue planes Use of adrenaline is debated MI and ischemia reported Injectates delivered using 21 to 25G needles Viscous injectates require wide bore needle ERBE hybridKnife does not need a separate needle.
- 16. ENDOSCOPES Endoscopes withhigh definition imaging may allow superior detection and demarcation of mucosal neoplasia Though they help detecting margin extent no added benefit in the procedure obtained A newly developed scope with channel diameter of 3.7mm has superior optics and suctioning facility. Endoscope with double channel may add on the advantage of using knife and grasping forceps together but add on the cost.
- 17. ENDOSURGICAL UNIT (ESU) Either a monopolar or bipolar circuit can be used. Newer ESUs contain microprocessor that sense voltage change due to tissue impedance and responsively keep the voltage constant to attend consistent effect. Newer ESUs have wide array of voltage ranges to facilitate cutting in different tissues. ESUs are also capable of APC for marking and hemostasis.
- 18. GAS INSUFFLATION Standardair insufflation is safe for use in ESD CO2 absorbed 160 times more faster than nitrogen and 13 times more than O2 CO2 insufflation less prolonged, less pt. discomfort, fewer post procedure admissions Decreased likelihood of tension pneumoperitoneum and perforation.
- 19. SEDATION Can bedone in moderate or deep sedation using midaz and propofol respectively Preferably by anesthetist Need of fine motor movement, longer duration of procedure, reflux potential, aspiration risk and risk of perforation makes GA naturally better choice.
- 20. INDICATIONS OF ESD ESD aiming for curative treatment should be performed in tumors without LN mets. LN mets strongly correlates with Depth of invasion Histopathologic type Lymphatic or vessel involvement Wehmann Endo. Sur 1994 Detailed examination, NBI/chromoendoscopy, targeted Bx should be done preprocedure Depth of invasion can be ascertained with mini probe in EUS – accuracy 80-92%. Okada Surg. Endo -2011
- 21. ESOPHAGUS – SCCa- ESD with complete resection curative only of tumor limited to epithelium and lamina propria muscle layer Those invading the musclaris mucosa and beyond have significant LN mets risk Till date no superficial Barrett esophageal ca. within the mucosa found to be associated with positive LN mets. Therefore, Ca. those limited within the mucosa and high grade dysplasia can be resected with curative results. Virchow Arch 2010
- 22. GASTRIC ESD Nolimitation of size ( unlike EMR <2cm) Japanese gastric cancer asso. – any lesion that can be resected in one piece and has minimal risk of LN mets Absolute indication non ulcerated Differentiated type Mucosal carcinoma < 2cm Expanded indication Non ulcerated, differentiated >2cm Ulcerated, differentiated but <3cm Non ulcerated, undifferentiated mucosal type <2cm Differentiated minimally invasive submucosal <5oomicron from muscularis mucosae <3cm.
- 23. COLORECTAL ESD Consideredcurative for benign adenoma, non invasive or minimally invasive ca. without vessel infiltration No size limitation Additional surgical treatment required if Positive vertical margin Depth >1000micron Vessel infiltration Poorly differentiated type Considered curative when all above are absent
- 24. EFFICACY AND COMPARISONS Stomach ESD for EGD En bloc resection – 86-97% R0 i.e. negative lateral and horizontal margin – 88-93% Local recurrence rate 1 % 5 year survival (overall) 96-100% Disease specific survival 99-100% Tanabe Gastric Cancer 2014 Goto endoscopy 2009
- 25. Two meta-analyses– comparing EMR with ESD Lian J GIE 2012 All cause mortality at 3 and 4 years did not differ significantly No comparative studies with surgery Lap gastrectomy for early ca stomach – 5 year survival 99.8% for T1a andT1B 98.7 ESD EMR En block 92% 52% R0 82-92% 42-43% Recurrence 0.8% 5.0-6.4%
- 26. COLON AND RECTUM Generally for laterally spreading tumor >2cm R0 resection – 88% Incidence of lymphatic metastasis when curative criteria fulfilled – 1.9% Comparison with EMR Comparing with surgical Rx. (Transanal endoscopic microsurgery) - only retrospective data Similar rates of R0 resection and curative resection between the 2 modalities, but shorted length of stay with ESD. ESD EMR Enblock 84-95% 33-57% Local recurrence 0-2% 12-26% Park SU Endoscopy 2012
- 27. ESOPHAGUS For Sq.CCrate of en-block resection 100% with curative resection rate 68-79% Non curative resection patient managed with esophagectomy In curative resection group no recurrences or mets for 2 years follow up Yamada GIE 2013
- 28. For Barrett’sGerman study 90% en-block resection R0 38% (any dysplasia precludes R0) Follow up for 17 month 96% neoplasia free No direct comparison with surgery available, 5 year survival rate, T1a - adeno ca. 91% and SCC – 62% with surgery Gertier Surg Endo 2011
- 29. COMPLICATIONS, BLEEDING Minoroozing treated – coagulation current, significant ooze – hemostatic forceps Severe endoscopically unmanageable – reported prevalence 6 in 1244 early gastric ca. ESDs Delayed bleeding rate 4.5% - 15.6% Risk factors Size of the lesion > 4cm Resumption of antithrombotics
- 30. PPI (andH2 blockers) shown to be associated with decreased bleeding risk Mucosal protective agents(sucrafil) faster healing but no change in bleeding rates Majority (76%) occur in 24 hours Non gastric ESD delayed bleed Esophagus – 0-5.2% Colorectal – 2% Ishamoto dig Endoscopy - 2013
- 31. PERFORATION Frequency –Gastric - 4.5%, colorectal - 4.8%, esophageal 0-10%. Pooled statistics from Japan , 117 perforations – 115(98%) could be managed non-operatively Treatment – primary clip closure – for defect <1cm, omental patch for larger lesions using multiple clip after suctioning lesser omentum. Initial management – NG suction – 3days,TPN for 9 days with antibiotic cover.
- 32. Colorectal ESDs– in a series of 816 ESDs, 16(2%) perforation occurred. Of which 14 treated endoscopically and only 2 needed surgery Esophageal perforation can be managed with clips only rare surgical intervention needed Small percentage may present with delayed perforation, in a series 1159, 6 presented after 10 hours of which 5 needed surgery.
- 33. STRICTURE Esophageal stricture(postESD) defined as – narrowing through which a standard gastroscope cannot be advanced Rate – 12-17% after esophageal ESD When circumference >3/4th resected, risk increase Serial dilatation, steroids radial electroincision, prophylactic SEMS can be used. After gastric ESD rare - 0.7% of all cases, majority near cardia and rest near prepyloric antrum Post Colorectal ESD strictures not reported Kim Dig Dis Sci 2014
- 34. MISCELLANEOUS Learning curve– minimum of 50 human procedures are needed to be performed for significant improvement across all outcomes Average procedure time in non Japanese institutes – 70-136min Cost of knives range between 400-700$(~24000 Rs)
- 35. FUTURE RESEARCH RCTscomparing EMR and surgery Newer agents that would can used for auto-dissection of the submucosa – Mesna in research, promising reports in animal studies. Development of agents that would shield the defects and prevent bleeding and perforation -- polyglycolic acid sheets and fibrin glue in development Development of endoscopic autologous oral mucosal sheets transplantation over the defects for stricture prevention.
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