The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.

BACKGROUND & AIMS: Esophagectomy is the standard treatment for stage I esophageal squamous cell carcinoma (ESCC). We conducted a single-arm prospective study to confirm the efficacy and safety of selective chemoradiotherapy (CRT) based on findings from endoscopic resection (ER). METHODS: We performed a prospective study of patients with T1b (SM1-2) N0M0 thoracic ESCC from December 2006 through July 2012; 176 patients underwent ER. Based on the findings from ER, patients received the following: no additional treatment for patients with pT1a tumors with a negative resection margin and no lymphovascular invasion (group A); prophylactic CRT with 41.4 Gy delivered to locoregional lymph nodes for patients with pT1b tumors with a negative resection margin or pT1a tumors with lymphovascular invasion (group B); or definitive CRT (50.4 Gy) with a 9-Gy boost to the primary site for patients with a positive vertical resection margin (group C). Chemotherapy comprised 5-fluorouracil and cisplatin. The primary end point was 3-year overall survival in group B, and the key secondary end point was 3-year overall survival for all patients. If lower limits of 90% confidence intervals for the primary and key secondary end points exceeded the 80% threshold, the efficacy of combined ER and selective CRT was confirmed. RESULTS: Based on the results from pathology analysis, 74, 87, and 15 patients were categorized into groups A, B, and C, respectively. The 3-year overall survival rates were 90.7% for group B (90% confidence interval, 84.0%-94.7%) and 92.6% in all patients (90% confidence interval, 88.5%-95.2%). CONCLUSIONS: In a prospective study of patients with T1b (SM1-2) N0M0 thoracic ESCC, we confirmed the efficacy of the combination of ER and selective CRT. Efficacy is comparable to that of surgery, and the combination of ER and selective CRT should be considered as a minimally invasive treatment option. UMIN-Clinical Trials Registry no.: UMIN000000553.

Background: Endoscopic submucosal resection (ESD) and endoscopic mucosal resection (EMR) are well established as curable and safety procedures for treating superficial tumors of the stomach, esophagus and colon. However, a majority of endoscopic resection strategies for non-ampullary superficial duodenal tumors (NASDTs) remains undefined. The aim of this study was to clarify which was the right method for NASDT treatment - EMR or ESD. Summary: We analyzed 129 consecutive endoscopic resection (74 ESD and 55 EMR) procedures performed with NADSTs and divided the ESD group into 49 large ESD groups (more than 20 mm in diameter) and 25 small ESD groups (less than 20 mm in diameter). With respect to the technical outcomes of EMR/ESD for small size NASDTs, EMR was safer than ESD, but its nature of curability was inferior to that of ESD. The rates of complication such as perforation or delayed bleeding were significantly higher in both ESD groups than in the EMR group. However, the prophylactic endoscopic closure of large mucosal defects after ESD was useful for resolving those complications. The limitations of our study were involvement of a single-center, limited sample size, short follow-up duration and the retrospective design, which may have introduced selection bias. However, the present findings suggest that adequate endoscopic treatment strategy for NASDTs can lead to favorable outcomes and an excellent prognosis. Key Message: It is necessary to select EMR or ESD adequately for R0 resection of small NASDTs, according to their size and location. For large NASDTs, duodenal ESD with essential management is feasible and useful as a therapeutic procedure.

PGA sheets may have the potential to prevent esophageal stricture.

Background and Aim: A novel diagnostic algorithm for magnifying endoscopy with narrow band imaging (ME-NBI) for superficial non-ampullary duodenal epithelial tumors (SNADET) is needed because of diagnostic difficulties. Methods:In the present study, ME-NBI images taken prior to endoscopic treatment were retrospectively analyzed to investigate the relationship between ME-NBI findings and pathological findings. Lesions displaying a single surface pattern were classified as monotype, and those displaying multiple surface patterns as mixed type. Surface pattern was classified as preserved, micrified, or absent. In addition, vascular pattern was classified as absent, network, intrastructural vascular (ISV), or unclassified. Results: According to the revised Vienna classification, 100%(23/23) of mixed-type lesions were category 4/5 tumors, whereas approximately 50% (10/23) of monotype lesions were category 3 tumors. In the monotype lesions, the probability of category 4/5 tumor was 100% (2/2) in lesions with an unclassified vascular pattern, 64.3% (9/14) in lesions with an ISV pattern, 33.3% (1/3) in lesions with an absent pattern, and 25.0% (1/4) in lesions with a network pattern. Conclusion:These findings suggest the possibility of developing an effective diagnostic algorithm for ME-NBI for SNADET by determining their surface pattern and vascular pattern.

We concluded that lesions exceeding 5 mm in diameter should be treated by ESD, although a high resection rate is obtained also with EMR for lesions of 5 mm or less in diameter.

Endoscopic submucosal dissection for residual/locally recurrent lesions was curative and efficacy. This procedure could help to avoid surgical resection and frequent follow-up examinations in many patients.

Background: Esophagogastric junction (EGJ) cancers are not only located in regions anatomically difficult for endoscopic submucosal dissection (ESD), but they also have higher clinicopathological malignant potential than non-junctional gastric cancers (NJC). Despite this, no ESD-based comparative studies of junctional cancer (JC) and NJC have been conducted to date. The aims of this study were to clarify the clinicopathological characteristics of EGJ cancers and the short- and long-term outcomes after ESD. Methods: Between April 2005 and December 2010, ESD was performed on 1,463 lesions that were divided into the following three groups: Barrett’s adenocarcinoma (BA; n = 25); JC (n = 103), and NJC (n = 1,335). They were assessed for short-term outcomes, clinicopathological malignancy and long-term outcomes. Results: Rates of complete and curative resection were significantly lower for BA than for JC and NJC (64.0 vs. 96.1 and 96.0%; and 48.0 vs. 80.6 and 85.8%, respectively). The perforation rate was significantly higher for BA than for JC and NJC (20.0 vs. 2.9 and 2.7%). Clinicopathologically, submucosal invasion rates were higher in BA and JC than in NJC (32.0 and 30.1 vs. 13.6%), and positive rates of lymphatic and/or vascular invasion were remarkably higher in BA and JC versus NJC (24.0 vs. 9.7 vs. 4.8%, respectively). The 5-year survival rate in all patients with curative resection was 100%. Conclusion: This study confirmed the technical and theoretical validity of ESD for EGJ as a diagnostic treatment. However, we have to pay attention to the high rates of submucosal and lymphovascular invasive malignant potential of these cancers.