The Safety And Efficiency Of Endoscopic Submucosal Dissection In Gastroesophageal Mucoscal Lesions

Objective: To evaluate the safety and efficiency of endoscopic submucosal dissection for the treatment of gastroesophageal mucoscal lesions.Methods: 48 flat lesions of gastroesophagus detected by gastroscopy were studied from November 2005 to January 2009 (including 5 esophageal lesions and 43 gastric lesions), and were also confirmed as intraepithelial neoplasia, early carcinoma and ectopic pancreas and cyst by pathological examination. Furthermore, some were identified by endoscopic ultrasonography including gastrointestinal stromal tumors originated from muscularis mucosa, lipoma originated from submucosa and polypus with diameter more than 1.0 cm. The upper abdominal CT and/or endoscopic ultrasonography were done for the early carcinomas confirmed by pathology to exclude lymph nodes metastasis. Among 48 patients, there were 32 men and 16 women, and the age was from 23 to 82 years old, and the average age was 56.5±16.7.All patients were treated under conscious condition, the lesions were resected as en bloc with improved needle hook knife, IT knife or electro-coagulation or electro-cutting technique. The wound surface were handled with cold noradrenaline physiological saline, argon plasma coagulation and metal tongs. And they were treated with fasting, restraining acid secretion and other treatments at post-operation. The gastroscopy was performed to evaluate the status of wound surface and lesion residual for all patients one and/or six months later of post-operation.Results: Among the 48 patients, There were 41 cases of mucosal lesions, and their diameter was 0.7-3.0cm, and the average was 1.2±0.5cm,there were 35 patients (85.4%) with endoscopic en bloc resection by ESD, 6 patients (14.6%) with part resection by ESD and 6 patients (14.6%) with endoscopic resection by snare. The operation time for ESD was 25-75 minutes (average 43.0±16.8 minutes). There were 7 cases of submucosal lesions, and their diameter was 0.6-2.0cm, and the average was l.l±0.5cm, and the operation time for ESD was 30-50 minutes (average 40.0±17.2 minutes). In these 7 cases, 6 cases were resected for en bloc by ESD (85.7%), one case was resected by snare (14.3%). All patients had pathological outcomes which were consistent with the pre-operation of ESD. 2 cases were positive for the incisal margin and the others were negative. Among 41 cases with mucosal lesions, there were eight early gastric carcinomas (four intramucosal carcinomas and four early carcinomas infiltrated into mucous layer and partial submucosa). Two early esophageal carcinomas were found, and one was intramucosal carcinoma and another infiltrated into mucous layer and partial submucosa. One bleeding were occurrenced at peri-operation (2.4%) in,one raised lesion with diameter of 3 cm whose pathological outcome was tubulovillous adenoma with canceration, and then they were successfully treated by metal tongs and/or APC under endoscopy. Two perforations happened in operation (4.8%), one for early gastric carcinoma in gastric antrum with diameter of 1.0cm and another for gastrointestinal stromal tumor of gastric fundus with diameter of 1.5cm, and then were healed by metal tongs and other treatments 5-7 days later. One esophageal stenosis happened after ESD for esophageal carcinoma, and then was treated under endoscopy. No patient, was demanded the surgical operation for complication of ESD. One patient with gastric carcinoma was sent to surgery for worrying about the completely of ESD. Among 7 cases of submucosal lesions, one bleeding, that was ceased by noradrenaline physiological saline and metal tongs under enderscope, happened at post-operation for lipoma of gastric body with diameter of 0.8cm. There were 6 patients with wound surface less than 2.0cm, and none complication was occurred. While there were 42 patients with wound surface more than 2.0cm, and the complications were occurred in 4 cases including 2 bleeding and 2 perforations, which were successfully treated under endoscope. There were 4 cases whose lesions were originated from lamina muscularis muscosae, and one perforation happened. While one perforation and two bleeding happened in 5 cases with mucosal lesions involved submucosa. There was higher incidence rate of complications of ESD, when the submucosa was involved in. All patients were performed endoscopy for one month follow-up. The wound surfaces were completely cured in 21 cases (43.8%) and partly cured in 27 cases (56.2%). Little lesion Was remained in two cases. There were 31 cases with six moth follow-up by gastroscopy, the wound surfaces were completely cured in these cases and no recurrence was found.Conclusions: ESD could excise the early gastric carcinomas, early esophageal carcinomas and other mucosal lesions as en bloc, and could provide complete pathologic data. The recurrence was low and the complication was few. ESD was a safe and effective therapeutic method for early gastric and/or esophageal carcinomas and part of submucosal tumors.