Grasping forceps assisted endoscopic mucosal resection of early gastric cancer with a novel 2-channel prelooped hood

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1 Grasping forceps assiste enoscopic mucosal resection of early gastric cancer with a novel 2-channel preloope hoo Keiichiro Kume, MD, Masahiro Yamasaki, MD, Kikuo Kana, MD, Machiko Hirakoba, MD, Toru Matsuhashi, MD, Noriyoshi Santo, MD, Kazutaka Syukuwa, MD, Ichiro Yoshikawa, MD, Makoto Otsuki, MD Kitakyusyu, Japan Backgroun: Enoscopic mucosal resection with a cap-fitte panenoscope (EMRC) such as a soft preloope hoo is a useful, effective, an safe technique. One problem with this metho is that the lesion cannot always be maintaine in the center of the cap because the proceure is performe blinly after aspiration. Objective: We evelope a 2-channel preloope hoo that facilitates EMRC while simultaneously allowing both grip of the center in the lesion an irrigation of the aspiration site an evaluate the usefulness of this en hoo for early gastric cancer. Design: Retrospective stuy. Setting: Between August 2003 an October 2004, patients unerwent our novel EMR. Patients: Twelve cases of early gastric cancer. Interventions: Two sie holes were fabricate by rilling in the cap portion of a conventional soft preloope hoo, an then the irrigation tube an the accessory channel tube were glue to the exterior surface of the holes. We place the fabricate transparent hoo at the tip of the enoscope an performe grasping forceps assiste enoscopic aspiration mucosectomy. Main Outcome Measurements: Accurate aspiration an the rate of en bloc resection. Results: We obtaine a satisfactory fiel of view an accurate aspiration in the center of the tumor in all lesions. The rate of en bloc resection was 91.7% (11/12). Limitations: Gastric intramucosal cancer. Conclusion: Grasping forceps assiste enoscopic mucosal resection with a novel 2-channel preloope hoo is safe an useful for mucosal resection of intramucosal cancers less than 20 mm an may help center the lesion in the cap before resection. A cap-fitte pan enoscope preloae with a transparent har plastic hoo 1-4 or soft preloope hoo 5,6 on the en of a stanar front-viewing enoscope is useful for enoscopic mucosal resection (EMR). EMR with a cap-fitte pan enoscope (EMRC) proceure is simple, requires no special enoscope, an enables performance of the resection easily irrespective of the site of the lesion of interest. 1-6 In aition, the time require for EMR with the use of this evice is short. The isavantage with this metho, however, is the ifficulty in maintaining the lesion in the center of the hoo because the proceure is performe blinly after aspiration. Hence, we recently Copyright ª 2006 by the American Society for Gastrointestinal Enoscopy /$32.00 oi: /j.gie reporte the usefulness of an original irrigation preloope hoo that facilitates EMRC while repeately allowing aequate irrigation of the aspiration site. 6 We repeately performe aspiration of the lesion until the lesion was stabilize in the center of the hoo. If the fiel of view at the aspiration site was poor as a result of contamination by mucus an bloo, we repeately irrigate the site Centering the lesion in the center of the cap is important to maximize the chance that resection is performe en bloc. However, this can be ifficult to achieve in practice because the lesion may not raise evenly into the cap uring suctioning. In aition, bleeing occurring because of suction, although minor, can also obscure visualization. Thus, the lesion may not be resecte en bloc. En-bloc resection is important for pathologic evaluation an has been shown to be an important factor in preventing local recurrence. In this report, we use a 2-channel preloope 108 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 1 :

2 Kume et al Grasping forceps assiste EMR with a novel 2-channel preloope hoo Capsule Summary What is alreay known on this topic Transgastric rainage an necrosectomy are emerging options for infecte necrotizing pancreatitis. These proceures require repeate enoscopic interventions, small-caliber nasocystic rainages, an a nasojejunal feeing tube. What this stuy as to our knowlege Figure 1. The 2-channel soft preloope hoo. The irrigation tube (A) an the accessory channel tube (B) were glue to the exterior surface of the hole. The snare protruing from the accessory channel tube was preloope into the groove in the rim of the hoo (C). A sie hole in the irrigation tube in the cap portion was rille at an angle so the injecte water (D) crosse the crossing of the grasping apparatus protruing from the forceps hole of the enoscope boy (E) an the horizontal line of the cap intersect (F). hoo, which allows grasping the center of the lesion uring suctioning an irrigating the lesion before resection. MATERIAL AND METHODS Design of evice an enoscopic proceure We recently evelope a novel, soft irrigation preloope hoo that was constructe by rilling a sie hole in the cap portion of a conventional preloope soft hoo (18.5 mm iameter; D w06, Olympus, Tokyo, Japan) followe by attaching an irrigation tube. 6 This hoo was fabricate so that the insie of the transparent hoo coul be irrigate at all times through the tube. The 2-channel preloope hoo was prouce by rilling another sie hole in aition to the hole of the irrigation tube at the cap portion of a transparent en hoo. An irrigation tube (Fig. 1A) an an accessory channel tube (Fig. 1B) were glue to the exterior surface over the hole an attache at the insie of the cap. The sie hole mae in the cap portion was rille at an angle so that the injecte irrigation water (Fig. 1D) crosse the crossing of the grasping apparatus protruing from the forceps hole of the enoscope boy (Fig. 1E) an the horizontal line of the cap intersect (Fig. 1F). Patients Between August 2003 an October 2004, 12 patients (8 male, 4 female; mean age 71.1 years) unerwent EMR by use of the 2-channel preloope hoo for early gastric cancer. All cancers were confirme to be well ifferentiate aenocarcinoma by preoperative histopathologic In 2 cases, large pancreatic necroses were treate successfully with percutaneous transgastric retroperitoneal flushing tubes an a percutaneous transgastric jejunal feeing tube, couple with enoscopic necrosectomy. This ouble percutaneous enoscopic gastrostomy system allows for high-volume irrigation of retroperitoneal necroses an continuous enteral nutrition an eliminates transnasal rainage or feeing tubes. evaluation of biopsy specimens. The epth of invasion of cancerous lesions was examine by EUS. Informe consent was obtaine from all patients, an the stuy protocol conforme to the ethical guielines of the 1989 Declaration of Helsinki. Enoscopic proceure We first performe conventional enoscopy to mark the periphery of the lesion by electrocoagulation with a neele knife an to inject saline solution into the submucosa. Next, we place the fabricate transparent hoo at the tip of the enoscope an fixe it with tape. We then inserte the crescent-shape snare (SD-221L-25, SD-7P-1, Olympus) through the accessory channel tube of the en hoo an preloope this snare into the groove of the rim of the hoo (Fig. 1C). We performe this prelooping by lightly pressing against an aspirating the normal mucosa to seal the hoo outlet. The snare was opene an was force to rest along the insie groove of the rim of the hoo to form the loop. We release the negative aspiration pressure while slowly pulling the regular biopsy forceps, which grippe the center of the lesion. Until the lesion was stabilize in the center of the hoo, we repeately performe grasp an aspiration of the lesion. If the fiel of view at the aspiration site was poor as a result of contamination by mucus an bloo, we repeately performe irrigation of the site. After strangulating the lesion by closing the snare, we again release the aspiration. It took approximately 30 secons to allow the snare to close snugly. At this time, the lesion looke similar to a snare polypoi lesion. We repeately performe snaring of the lesion until this snare polypoi lesion inclue all marks of the periphery of the lesion. We use blene electrosurgical current to resect the lesion. Volume 64, No. 1 : 2006 GASTROINTESTINAL ENDOSCOPY 109

3 Grasping forceps assiste EMR with a novel 2-channel preloope hoo Kume et al Figure 2. EMR with the 2-channel soft preloope hoo. A, Enoscopic view showing type IIa gastric cancer. B, Electrosurgical marking of the margins of the lesion with the tip of the snare. C, Unsatisfactory enoscopic view because aspiration misse the center. D, Spurting bleeing from the lesion uner irrigation. E, Accurate aspiration while pulling the forceps, which are gripping the center of the lesion. F, Appearance of bleeing immeiately after enoscopic resection. G, Enoscopic clipping while simultaneoulsly irrigating the hemorrhage site. H, Appearance after enoscopic clipping. 110 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 1 :

4 Kume et al Grasping forceps assiste EMR with a novel 2-channel preloope hoo If bleeing was observe after resection, we performe enoscopic hemostasis uner irrigation (EHUI) (Fig. 2). En bloc resection, efine as EMR of the entire lesion as a 1-step proceure, was confirme by referring to the mucosal marks mae before resection. After measurement of the longest horizontal iameter, the EMR specimen was fixe in 10% formalin, an thin sections were prepare at 2-mm intervals for histopathologic evaluation. After complete resection, patients unerwent enoscopic surveillance at 3, 6, an 12 months an later after initial enoscopic resection. RESULTS During EMRC, by use of the 2-channel soft preloope hoo, we obtaine a satisfactory fiel of view an an accurate aspiration of the center in the tumor in all lesions. The mean longest iameter of specimens was 22.3 mm (interquartile range mm), an the meian iameter of lesions was 13.0 mm (interquartile range 7-24 mm). The rate of en bloc resection was 91.7% (11/12). One patient with a tumor 24 mm in iameter unerwent 2 resections. Bleeing was the only complication, an it occurre immeiately after EMR in 3 cases. Bleeing was easily controlle in all cases by EHUI: hemoclip was applie in 2 patients an electrocoagulation by hot biopsy in 1 patient (Table 1). Repeate grasping an aspiration i not cause pathologic changes to intramucosal cancer but i cause small traumas. All patients remain free from enoscopic recurrence uring a mean follow-up perio of 12.2 months (range 9-20 months). DISCUSSION In our experience, EMRC is simpler an easier compare with other EMR methos. An avantage of EMRC is that lesions can be approache frontally even if they are locate in regions that can be visualize only tangentially. 1-6,12,13 With this proceure the size of specimen obtaine from en-bloc resection is very limite (approximately mm on average). Inee, it is ifficult to resect lesions larger than 10 to 15 mm in one piece, 3,12 an resection in 2 or more steps has recently been inicate for large legions. On the basis of the inications for EMR of early gastric cancer, accurate resection of intramucosal cancer of %20 mm is neee If en-bloc resection is to be achieve, it frequently is necessary to obtain specimens greater than 20 mm in iameter an to aspirate the center of the tumor. Gastric specimens greater than 20 mm in iameter can be resecte with use of a soft preloope hoo. 5,6 Repeate aspiration of tumor lesions may cause a poor fiel of enoscopic view as a result of oozing TABLE 1. Summary Case Age (y) Sex Macroscopic appearance* Diameter of lesion (mm) Diameter of specimen (mm) 1 57 M IIc M IIa F IIa M IIc M IIa F IIc M IIc F IIc M IIa F IIa M IIc M IIa M, Male; IIc, superficial epresse type;.iia, superficial elevate type; F, female. hemorrhage cause by aspirating. 6 We previously aime for an accurate aspiration by using an original soft irrigation preloope hoo that facilitates EMRC while repeately allowing aequate irrigation of the aspiration site. However, the lesion may not be stabilize in the center of hoo by repeate aspirations. Actually, EMR of lesions larger than 16 mm require multipiece resection with an original soft irrigation preloope hoo. 6 Enoscopic aspiration mucosectomy by pushing the snare tissue out of the cap for visualization before resection was useful an obtaine the precise aspiration an an en-bloc resection. 13 But this proceure may get out of position in the center of the lesion because it cannot be confirme by both prelooping snare an center of the lesion. Therefore, we evelope a 2-channel soft preloope hoo with an another accessory tube in aition to an irrigation tube. This new evice mae it possible to improve the visual fiel at the tumor site, which coul be poor as a result of oozing hemorrhage by repeate aspiration of the tumor lesion, an to perform precise aspiration by allowing pull of the forceps grippe in the center of the lesion. Grasping forceps assiste enoscopic mucosal resection with a novel 2-channel preloope hoo facilitate EMRC while simultaneously allowing both irrigation of the aspiration site an grasp of the center of the lesion. It was easy to resect lesions smaller than 15 mm in 1 piece by using both the previous evice an the new evice. But EMR performe with the new evice coul achieve en-bloc resection with a maximum size of 22 mm. Volume 64, No. 1 : 2006 GASTROINTESTINAL ENDOSCOPY 111

5 Grasping forceps assiste EMR with a novel 2-channel preloope hoo Kume et al Bleeing was the major complication of EMR. We coul treat active bleeing immeiately after EMR by the EHUI metho. In conclusion, EMR with a 2-channel soft preloope hoo is useful, particularly in cases of intramucosal cancer less than 20 mm. REFERENCES 1. Inoue H, Takeshita K, Hori H, et al. Enoscopic mucosal resection with a cap-fitte panenoscope for esophagus, stomach an colon mucosal lesions. Gastrointest Enosc 1993;39: Torii A, Sakai M, Kajiyama M, et al. Enoscopic aspiration mucosectomy as curative enoscopic surgery: analysis of 24 cases of early gastric cancer. Gastrointest Enosc 1995;42: Tanabe S, Koizumi W, Kokutou M, et al. Usefulness of enoscopic aspiration mucosectomy as compare with strip biopsy for the treatment of gastric mucosal cancer. Gastrointest Enosc 1999;50: Soetikno RY, Gotoa T, Nakanishi Y, et al. Enoscopic mucosal resection. Gastrointest Enosc 2003;57: Matsuzaki K, Nagao S, Kawaguchi A, et al. Newly esigne soft preloope cap for enoscopic mucosal resection of gastric lesions. Gastrointest Enosc 2003;57: Kume K, Yamasaki M, Kubo K, et al. EMR of upper GI lesions when using a novel soft, irrigation, preloope hoo. Gastrointest Enosc 2004; 60: Kume K, Yoshikawa I, Otsuki M. Enoscopic treatment of upper GI hemorrhage with a novel irrigating hoo attache to the enoscope. Gastrointest Enosc 2003;57: Kume K, Yamasaki M, Yamasaki T, et al. Enoscopic hemostatic treatment uner irrigation for upper GI hemorrhage: a comparison of one thir an total circumference transparent en hoos. Gastrointest Enosc 2004;59: Kume K, Yamasaki M, Yamasaki T, et al. Enoscopic treatment of upper GI hemorrhage with an original irrigating hoo attache to the enoscope: a 1/3 partial transparent hoo versus a total transparent hoo. Gut 2003;52(Suppl):A Kume K, Yamasaki M, Kana K. Enoscopic submucosal issection using a novel irrigation hoo-knife. Enoscopy 2005;37: Kume K, Yamasaki M, Kana K, et al. Enoscopic proceure uner irrigation. Dig Enosc 2005;17: Matsushita M, Hajiro K, Okazaki K, et al. Enoscopic mucosal resection of gastric tumors locate in the lesser curvature of the upper thir of the stomach. Gastrointest Enosc 1997;45: Torii A, Sakai M, Kajiyama T, et al. Enoscopic aspiration mucosectomy as curative enoscopic surgery: analysis of 24 cases of early gastric cancer. Gastrointest Enosc 1995;42: Tani M, Sakai P, Kono H. Enoscopic mucosal resection of superficial cancer in the stomach using the cap technique. Enoscopy 2003;35: Maekawa S, Takeo S, Ikejiri K, et al. Clinicopathological features of lymph noe metastasis in early gastric cancer. Int Surg 1995;80: Nakamura K, Morisaki T, Sugitani A, et al. An early gastric carcinoma treatment strategy base on analysis of lymph noe metastasis. Cancer 1999;85: Tsujitani S, Oka S, Saito H, et al. Less invasive surgery for early gastric cancer base on the low probability of lymph noe metastasis. Surgery 1999;125: Receive December 17, Accepte February 25, Current affiliations: Thir Department of Internal Meicine, University of Occupational an Environmental Health, School of Meicine, Kitakyusyu, Japan. Reprint requests: Makoto Otsuki, MD, PhD, Thir Department of Internal Meicine, University of Occupational an Environmental Health, Japan, School of Meicine, 1-1, Iseigaoka, Yahatanishi-ku, Kitakyusyu , Japan. 112 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 1 :