Download PDF
Endoscopy 2010; 42(6): 475-480
DOI: 10.1055/s-0029-1244121
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic mucosal resection using a grasp-and-snare technique

D. von  Renteln1 , A.  Schmidt1 , M.  C.  Vassiliou2 , H.-U.  Rudolph3 , K.  Caca1
  • 1Department of Gastroenterology, Hepatology, and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
  • 2Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
  • 3University Hospital Mannheim, University of Heidelberg, Germany
Further Information

Publication History

submitted 13 May 2009

accepted after revision 10 February 2010

Publication Date:
29 April 2010 (online)

Also available at
    Permissions and Reprints

See also:

Commentaire de travail de D. von Renteln et al., pp. 475Endoscopy 2010; 42(06): 523-523
DOI: 10.1055/s-0031-1291866

Background and study aim: Endoscopic mucosal resection (EMR) is a minimally invasive method for en bloc removal of superficial gastrointestinal lesions. The aim of this study was to evaluate the feasibility of a novel grasp-and-snare EMR technique.

Methods: In 10 domestic pigs, gastric lesions of approximately 3 cm were marked using electrocautery. EMR was performed using a double-channel endoscope. A novel tissue anchor was used through one channel, and a monofilament snare through the other. After submucosal injection, a circumferential mucosal incision was created. The tissue-anchoring device was then advanced through the open snare and anchored into the submucosal layer. The tissue-anchoring device was partly retracted into the endoscope and the snare was positioned into the circular incision. The snare was subsequently closed and the specimen resected by applying high-frequency electrocautery.

Results: Mean time to perform EMR was 32.4 minutes (range 22 – 41 minutes, SD 6.3). EMR yielded specimens that ranged in area from 2.7 cm (minor axis) by 2.8 cm (major axis) to 4.0 cm by 4.2 cm (mean area 9.36 cm2; range 5.94 – 13.19 cm2; SD ± 2.50). Complete en bloc resection including all electrocautery markings was achieved in 9/10 cases. In one case, resection was achieved in two steps. One gastric wall perforation occurred. No other adverse events were observed.

Conclusions: Grasp-and-snare EMR is feasible in an animal model. The technique can be performed efficiently compared with standard methods. To avoid perforation, caution is needed to ensure that tissue anchor needles are placed within and not deeper than the submucosal layer prior to tissue retraction.

References

  • 1 Das A. Endoscopic submucosal dissection – cure in one piece.  Endoscopy. 2006;  38 1044-1046
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Kojima T P-BA, Takahashi H, Fujita R. Outcome of endoscopic mucosal resection for early gastric cancer: review of the Japanese literature.  Gastrointest Endosc. 1998;  48 550-554
    CrossrefPubMedGoogle Scholar
  • 3 Gotoda T, Yanagisawa A, Sasako M. et al . Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers.  Gastric Cancer. 2000;  3 219-225
    CrossrefPubMedGoogle Scholar
  • 4 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
    CrossrefPubMedGoogle Scholar
  • 5 Stein H J, Feith M, Bruecher B L. et al . Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection.  Ann Surg. 2005;  242 566-573; discussion 573 – 565
    PubMedGoogle Scholar
  • 6 Ishihara R, Iishi H, Takeuchi Y. et al . Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection.  Gastrointest Endosc. 2008;  67 799-804
    CrossrefPubMedGoogle Scholar
  • 7 Takenaka R, Kawahara Y, Okada H. et al . Risk factors associated with local recurrence of early gastric cancers after endoscopic submucosal dissection.  Gastrointest Endosc. 2008;  68 887-894
    CrossrefPubMedGoogle Scholar
  • 8 Goto O, Fujishiro M, Kodashima S. et al . Outcomes of endoscopic submucosal dissection for early gastric cancer with special reference to validation for curability criteria.  Endoscopy. 2009;  41 118-122
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Vieth M, Rosch T. Endoscopic mucosal resection and the risk of lymph-node metastases: indications revisited?.  Endoscopy. 2006;  38 175-179
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Deyhle P FL, Jenny S, Fumagalli I. A method for endoscopic electroresection of sessile colonic polyps.  Endoscopy. 1973;  5 38-40
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Deyhle P S, Sulser H, Säuberli H. Endoscopic snare ectomy of an early gastric cancer – a therapeutical method?.  Endoscopy. 1974;  6 195-198
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Sauberli H, Sulser H, Deyhle P. [Endoscopic ectomy of early gastric cancer using the diathermy loop – a therapeutic method].  Helv Chir Acta. 1976;  43 529-532
    PubMedGoogle Scholar
  • 13 Deyhle P. Results of endoscopic polypectomy in the gastrointestinal tract.  Endoscopy. 1980;  12 35-46
    PubMedGoogle Scholar
  • 14 Rosch W, Fruhmorgen P. Endoscopic treatment of precancerous and early gastric carcinoma.  Endoscopy. 1980;  12 109-113
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Wolff W I, Shinya H. A new approach to the management of colonic polyps.  Adv Surg. 1973;  7 45-67
    PubMedGoogle Scholar
  • 16 Wolff W L, Shinya H. Colonofiberoscopy: diagnostic modality and therapeutic aplication.  Bull Soc Int Chir. 1971;  30 525-529
    PubMedGoogle Scholar
  • 17 Kantsevoy S V, Adler D G, Conway J D. et al . Endoscopic mucosal resection and endoscopic submucosal dissection.  Gastrointest Endosc. 2008;  68 11-18
    CrossrefPubMedGoogle Scholar
  • 18 Miyamoto S, Muto M, Hamamoto Y. et al . A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms.  Gastrointest Endosc. 2002;  55 576-581
    CrossrefPubMedGoogle Scholar
  • 19 Gotoda T, Kondo H, Ono H. et al . A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases.  Gastrointest Endosc. 1999;  50 560-563
    CrossrefPubMedGoogle Scholar
  • 20 Fujishiro M, Yahagi N, Kakushima N. et al . Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms.  Endoscopy. 2006;  38 1001-1006
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Fujishiro M, Yahagi N, Nakamura M. et al . Endoscopic submucosal dissection for rectal epithelial neoplasia.  Endoscopy. 2006;  38 493-497
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Fujishiro M, Yahagi N, Nakamura M. et al . Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar.  Gastrointest Endosc. 2006;  63 243-249
    CrossrefPubMedGoogle Scholar
  • 23 Imaeda H, Iwao Y, Ogata H. et al . A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps.  Endoscopy. 2006;  38 1007-1010
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Imagawa A, Okada H, Kawahara Y. et al . Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success.  Endoscopy. 2006;  38 987-990
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Kakushima N, Fujishiro M, Kodashima S. et al . Histopathologic characteristics of gastric ulcers created by endoscopic submucosal dissection.  Endoscopy. 2006;  38 412-415
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Kakushima N, Fujishiro M, Kodashima S. et al . A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms.  Endoscopy. 2006;  38 991-995
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Kakushima N, Yahagi N, Fujishiro M. et al . Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction.  Endoscopy. 2006;  38 170-174
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Lee I L, Lin P Y, Tung S Y. et al . Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer.  Endoscopy. 2006;  38 1024-1028
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Neuhaus H, Costamagna G, Deviere J. et al . Endoscopic submucosal dissection (ESD) of early neoplastic gastric lesions using a new double-channel endoscope (the "R-scope").  Endoscopy. 2006;  38 1016-1023
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Oka S, Tanaka S, Kaneko I. et al . Endoscopic submucosal dissection for residual/local recurrence of early gastric cancer after endoscopic mucosal resection.  Endoscopy. 2006;  38 996-1000
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Oka S, Tanaka S, Kaneko I. et al . Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer.  Gastrointest Endosc. 2006;  64 877-883
    CrossrefPubMedGoogle Scholar
  • 32 Onozato Y, Ishihara H, Iizuka H. et al . Endoscopic submucosal dissection for early gastric cancers and large flat adenomas.  Endoscopy. 2006;  38 980-986
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Shimizu Y, Yamamoto J, Kato M. et al . Endoscopic submucosal dissection for treatment of early stage hypopharyngeal carcinoma.  Gastrointest Endosc. 2006;  64 255-259; discussion 260 – 252
    CrossrefPubMedGoogle Scholar
  • 34 Yonezawa J, Kaise M, Sumiyama K. et al . A novel double-channel therapeutic endoscope (”R-scope”) facilitates endoscopic submucosal dissection of superficial gastric neoplasms.  Endoscopy. 2006;  38 1011-1015
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Akahoshi K, Akahane H, Murata A. et al . Endoscopic submucosal dissection using a novel grasping type scissors forceps.  Endoscopy. 2007;  39 1103-1105
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Kume K, Yamasaki M, Yoshikawa I, Otsuki M. Grasping-forceps-assisted endoscopic submucosal dissection using a novel irrigation cap-knife for large superficial early gastric cancer.  Endoscopy. 2007;  39 566-569
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Onozato Y, Kakizaki S, Ishihara H. et al . Endoscopic submucosal dissection for rectal tumors.  Endoscopy. 2007;  39 423-427
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Tamegai Y, Saito Y, Masaki N. et al . Endoscopic submucosal dissection: a safe technique for colorectal tumors.  Endoscopy. 2007;  39 418-422
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Ogura K, Okamoto M, Sugimoto T. et al . Efficacy and safety of endoscopic submucosal dissection for gastric cancer in patients with liver cirrhosis.  Endoscopy. 2008;  40 443-445
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Yahagi N, Neuhaus H, Schumacher B. et al . Comparison of standard endoscopic submucosal dissection (ESD) versus an optimized ESD technique for the colon: an animal study.  Endoscopy. 2009;  41 340-345
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Zhou P H, Yao L Q, Qin X Y. Endoscopic submucosal dissection for colorectal epithelial neoplasm.  Surg Endosc. 2009;  41 340-345
    PubMedGoogle Scholar
  • 42 Kawahara Y, Takenake R, Okada H. Risk management to prevent perforation during endoscopic submucosal dissection.  Dig Endosc. 2007;  19 9-13
    CrossrefPubMedGoogle Scholar
  • 43 Tada M, Murata M, Murakami F. [Development of the strip-off biopsy].  Gastroenterol Endosc. 1984;  26 833-839
    PubMedGoogle Scholar
  • 44 Tada M, Murakami A, Karita M. et al . Endoscopic resection of early gastric cancer.  Endoscopy. 1993;  25 445-450
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Martin T R, Onstad G R, Silvis S E, Vennes J A. Lift and cut biopsy technique for submucosal sampling.  Gastrointest Endosc. 1976;  23 29-30
    CrossrefPubMedGoogle Scholar
  • 46 Takekoshi T, Takagi K, Fujii A, Kato Y. [Treatment of early gastric cancer by endoscopic double snare polypectomy (EDSP)].  Gan No Rinsho. 1986;  32 1185-1190
    PubMedGoogle Scholar
  • 47 Takekoshi T, Fujii A, Takagi K. et al . [Radical endoscopic treatment of early gastric cancer-indication for and evaluation of endoscopic resection].  Gan To Kagaku Ryoho. 1988;  15 1449-1459
    PubMedGoogle Scholar
  • 48 Karita M, Tada M, Okita K, Kodama T. Endoscopic therapy for early colon cancer: the strip biopsy resection technique.  Gastrointest Endosc. 1991;  37 128-132
    CrossrefPubMedGoogle Scholar
  • 49 Karita M, Tada M, Okita K. The successive strip biopsy partial resection technique for large early gastric and colon cancers.  Gastrointest Endosc. 1992;  38 174-178
    CrossrefPubMedGoogle Scholar
  • 50 Takemoto N, Baba Y, Takekoshi T. et al . [Endoscopic treatment of early gastric cancer].  Gan To Kagaku Ryoho. 1992;  19 1268-1273
    PubMedGoogle Scholar
  • 51 Tanabe S, Koizumi W, Kokutou M. et al . Usefulness of endoscopic aspiration mucosectomy as compared with strip biopsy for the treatment of gastric mucosal cancer.  Gastrointest Endosc. 1999;  50 819-822
    CrossrefPubMedGoogle Scholar
  • 52 Goto O, Fujishiro M, Kodashima S. et al . Is it possible to predict the procedural time of endoscopic submucosal dissection for early gastric cancer?.  J Gastroenterol Hepatol. 2009;  24 379-383
    CrossrefPubMedGoogle Scholar

D. von RentelnMD 

Department of Gastroenterology, Hepatology and Oncology
Klinikum Ludwigsburg

71640 Ludwigsburg
Germany

Fax: +49-7141-9967219

Email: renteln@gmx.net

      >