ИСТИНА

The presenter is Plakhov RV. In recent years, advanced endoscopic methods for removing of the mucosa are more commonly used for the treatment of patients with superficial epithelial gastric and duodenal lesions, including early cancer, sometimes as alternative for surgery. Aim: to analyze and compare the immediate outcomes endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for superficial epithelial gastric and duodenal lesions, based on the Japanese Gastric Cancer Association treatment guidelines. We analyzed complete and en bloc resection rate, operation time and quantity of complications. Materials&Methods: a total of 133 patients (pts.) with 145 superficial epithelial gastric and duodenal lesions have been treated with endoscopic methods removing of the mucosa in the hospital between I.2004 and I.2012. The results of that treatment were retrospectively analyzed. Amongst 133 pts. there were 39 male and 94 (70%) female (mean age M±s 58±16 years). Diagnostic program included conventional videoendoscopy, chromoendoscopy, excisional forceps biopsy, EUS, enhanced endoscopy. In our study pts for EMR and ESD were selected according to the Japanese Gastric Cancer Association treatment guidelines. EMR and ESD was performed with operative endoscopes 1Т 140 and Q 160, and two-channel endoscope 2Т 160 (Olympus, Japan). The methods of EMR were strip-off biopsy, lift and cut biopsy, EMR cap (EMR-C). The ESD was performed with IT-knife, hook knife, flex knife и triangle knife. Results: the lesions were located in antrum (45%, 65/145), corpus ventriculi (19%, 28/145), cardia (13%, 19/145), esophageal-gastric junction (12%, 17/145), duodenum (11% 16/145). Size of the lesions varied from 3 to 40 mm, but 87% of the lesions were in the range 3 to 20 mm. According to the Paris endoscopic classification of superficial neoplastic lesions (2002) identified lesions were classificated as 0Is (55%, 79/145), 0IIa+IIc (15%, 21/145), 0Isp (12%, 18/145), 0IIa - 12% (18/145), 0Ip – 3% (5/145), 0IIc -1% (2/145), 0IIb - 1% (1/145), 0Is-0III type of lesions - 1% (1/145). From 145 lesions only 140 were completely removed through the endoscope. In 5 cases lesions were not removed because of technical problems (2 cases) and profuse intraoperative bleeding quired laparotomy (3 cases). EMR was applied for 117 lesions and ESD – for 23 lesions. Both groups were similar to sex, age, localization and macrotype of lesions, in the group of ESD the more large lesions were included. In general relative en bloc resection rate was 73% (102/140; 95% CI 65 – 81): in the group of EMR - 70% (82/117), in the grope of ESD - 87% (20/23) (p=0,13, not significant). En bloc resection rate of conventional EMR was significantly higher for lesions measuring less to 15 mm then more large: respectively relative en bloc resection rate 78% (73/94, 95% CI 68 – 87) and 39% (9/23, 95% CI 15 – 63; p<0,001). In similar settings for ESD the difference is not significant: relative en bloc resection rate for lesions less 15 mm 100% (9/9, 95% CI 66 – 100), and more 15 mm - 79% (11/14, 95% CI 49 - 95; р=0,25). However ESD was significantly more effective then EMR in en bloc resection for superficial epithelial gastric and duodenal lesions more 15 mm in size (79 and 39% relative en bloc resection rate respectively, р=0,04). But ESD technique was significantly more time-consuming than conventional EMR technique. The time of operation in both groups has been compared: the median and quartiles were respectively 80 (60-120) and 40 (30-60) min (p<0,001). The technical problems happened in 2 cases of EMR, because of which resections have not been completed. Complications occurred in 10 cases endoscopic resection (8,3%, 10/121; 95% CI 2,6 - 14). Intraoperative complications during the EMR were in 3 cases: 1 perforation (1%, 1/121), which was eliminated by endoscopic clipping, and 2 severe bleeding (2%, 2/121), for stopping these the laparotomies were needed. Postoperative complications after the EMR included 7 bleeding from the site of resection (6%, 7/121), which were stopped through endoscopic haemostasis. The ESD technique in this study characterized by 12,5% of complications (3/24; 95% CI 0 – 29,8; p=0,71): 1 intraoperative bleeding (4%, 1/24) in a patient with coagulopathy, for stopping which the laparotomy and gastric resection were needed, but this patient died in 7 postoperational day from recurrent pulmonary embolism; and 1 postoperative bleeding (4%, 1/24), which were eliminated with endoscopic haemostasis and 1 perforation (4%, 1/24) on 2 day after operation in the coagulation zone. Postoperative histological study determined that 44% (63/143) of the superficial epithelial lesions were benign, 31% (44/143) of the lesions included the low grade neoplasia, 22% (31/143) – high grade neoplasia (including high grade dysplasia, cancer in situ, intramucous cancer), 3% (5/143) – invasive adenocarcinoma. Histological completeness of endoscopic cancer resection was determined. The resection results were classified as histologicaly complete in the case of high and middle differentiated type adenocarcinoma, negative margins, absence of lymphovascular invasion and deep submucosal invasion. A total of 18 early gastric cancers were treated with endoscopic methods. In the group of EMR 9 from 13 resections were complete (69%), in the grope of ESD 5 from 5 resections were complete (100%, difference is not significant). 4 EMR were not complete because of positive margins of resection zone, and in 1 case also the low differentiated tumor was detected. General complete resection rate was 78% (14/18). Conclusions: in our study we identified the advantages of endoscopic submucosal dissection over conventional EMR in en bloc resection for superficial epithelial gastric and duodenal lesions measuring more 15 mm, but also high duration of time ESD technique comparing with EMR. We did not found significant differences in the rate of intra- and post-operative complications for EMR and ESD techniques.