Endoscopic Submucosal Dissection for Early Gastric Cancer using the Clutch Cutter: a large single-center experience

Background and study aims: The Clutch Cutter (CC) was developed to reduce the risk of complications related to endoscopic submucosal dissection (ESD) using knives. The CC is able to grasp and coagulate and/or incise the targeted tissue using electrosurgical current, like a biopsy technique. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early gastric cancer (EGC).

Patients and methods: From June 2007 to March 2014, 325 consecutive patients with a diagnosis of EGC were enrolled in this prospective study. They had all satisfied the Japanese gastric cancer treatment guidelines for ESD indication, namely confirmation by preliminary endoscopy, endoscopic ultrasound, and endoscopic biopsies. The CC was used for all steps of ESD (marking, circumferential marginal incision, submucosal dissection, and hemostatic treatment). The therapeutic efficacy and safety were assessed.

Results: The en-bloc resection rate was 99.7 % (324/325) and the R0 resection rate was 95.3 % (310/325). The mean operating time was 97.2 minutes. Perforation during ESD-CC occurred in one case (0.3 %), which was managed with conservative medical treatment after endoscopic closure of the perforation. Post-ESD-CC bleeding occurred in 11 cases (3.4 %), which were successfully treated by endoscopic hemostatic treatment. The R0 resection rate was significantly low in tumors > 20 mm (88.9 %), and in the exclusion indication group (73.7 %). Significant differences were seen in the mean operating time, depending upon tumor size, histologic type, location, and indication criteria.

Conclusions: ESD-CC is a technically efficient, safe, and easy method for resecting EGC.

• References

• 1 Ono H, Kondo H, Gotoda T et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001; 48: 225-229
• 2 Kakushima N, Fujishiro M. Endoscopic submucosal dissection for gastrointestinal neoplasms. World. J. Gastroenterol 2008; 14: 2962-2967
• 3 Isomoto H, Shikuwa S, Yamaguchi N et al. Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study. Gut 2009; 58: 331-336
• 4 Lian J, Chen S, Zhang Y et al. A meta-analysis of endoscopic submucosal dissection and EMR for early gastric cancer. Gastrointest Endosc 2012; 76: 763-770
• 5 Chung II, Lee JH, Lee SH et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc 2009; 69: 1228-1235
• 6 Saito I, Tsuji Y, Niimi K et al. Complications related to gastric endoscopic submucosal dissection and their managements. Clin Endosc 2014; 47: 398-403
• 7 Yamamoto Y, Fujisaki J, Ishiyama A et al. Current status of training for endoscopic submucosal dissection for gastric epithelial neoplasm at Cancer Institute Hospital, Japanese Foundation for Cancer Research, a famous Japanese hospital. Dig Endosc 2012; 24 (Suppl. 01) 148-153
• 8 Akahoshi K, Akahane H. A new breakthrough: ESD using a newly developed grasping type scissor forceps for early gastrointestinal tract neoplasms. World J Gastrointest Endosc 2010; 2: 90-96
• 9 Akahoshi K, Akahane H, Motomura Y et al. A new approach: Endoscopic submucosal dissection using the Clutch Cutter for early stage digestive tract tumors. Digestion 2012; 85: 80-84
• 10 Akahoshi K, Akahane H, Murata A et al. Endoscopic submucosal dissection using a novel grasping type scissors forceps. Endoscopy 2007; 39: 1103-1105
• 11 Akahoshi K, Honda K, Akahane H et al. Endoscopic submucosal dissection using a grasping type scissors forceps: a preliminary clinical study. Gastrointest Endosc 2008; 67: 1128-1133
• 12 Akahoshi K, Honda K, Motomura Y et al. Endoscopic submucosal dissection using a grasping type scissors forceps for early gastric cancers and adenomas. Dig Endosc 2011; 23: 24-29
• 13 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
• 14 Japanese Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011; 14: 113-123
• 15 Min YW, Min BH, Lee JH et al. Endoscopic treatment for early gastric cancer. World J Gastroenterol 2014; 20: 4566-4573
• 16 Gotoda T. A large endoscopic resection by endoscopic submucosal dissection procedure for early gastric cancer. Clin Gastroenterol Hepatol 2005; 3: 71-S73
• 17 Tanaka M, Ono H, Hasuike N et al. Endoscopic submucosal dissection of early gastric cancer. Digestion 2008; 77 (Suppl. 01) 23-28
• 18 Nakamoto S, Sakai Y, Kasanuki J et al. Indications for the use of endoscopic mucosal resection for early gastric cancer in Japan: a comparative study with endoscopic submucosal dissection. Endoscopy 2009; 41: 746-750
• 19 Białek A, Wiechowska-Kozłowska A, Pertkiewicz J et al. Endoscopic submucosal dissection for the treatment of neoplastic lesions in the gastrointestinal tract. World J Gastroenterol 2013; 19: 1953-1961
• 20 Neuhaus H. Endoscopic submucosal dissection in the upper gastrointestinal tract: present and future view of Europe. Dig. Endosc 2009; 21: s4-s6
• 21 Probst A, Golger D, Arnholdt H et al. Endoscopic submucosal dissection of early gastric cancers, flat adenomas, and submucosal tumors in the gastrointestinal tract. Clin Gastroenterol Hepatol 2009; 7: 149-155
• 22 Mannen K, Tsunada S, Hara M et al. Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions. J Gastroenterol 2010; 45: 30-36
• 23 Watari J, Tomita T, Toyoshima F et al. Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: a prospective pilot study. World J Gastrointest Endosc 2013; 5: 281-287
• 24 Nonaka K, Kita H. Endoscopic submucosal dissection for early gastric cancer. J Cancer Ther 2013; 4: 26-32
• 25 Ikezawa K, Michida T, Iwahashi K et al. Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer. Gastric Cancer 2012; 15: 111-114
• 26 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112-1115
• 27 Oda I, Gotoda T, Hamanaka H et al. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Dig Endosc 2005; 17: 54-58
• 28 Tsuji Y, Ohata K, Ito T et al. Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions. World J Gastroenterol 2010; 16: 2913-2917
• 29 Fujishiro M, Chiu PW, Wang HP. Role of antisecretory agents for gastric endoscopic submucosal dissection. Dig Endosc 2013; 25: 86-93
• 30 Koh R, Hirasawa K, Yahara S et al. Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms. Gastrointest Endosc 2013; 78: 476-483