Falk Symposium 152
Endoscopy 2006
Berlin, 04.-05. Mai 2006
The most relevant new technologies –
Therapeutic GI Endoscopy
Nib Soehendra
Klinik und Poliklinik für Interdisziplinäre Endoskopie
Universitätsklinikum Hamburg-Eppendorf
Endoscopic Treatment of
Early GI Cancers
EMR
ESD
Early Gastric Cancer:
Curability and Local Recurrence
1987-1999, NCCH
Recurrence rate (%)
curable
nontotal
curable
Single
fragment
Multiple
fragments
0
5.7
(0/316)
(7/122)
(7/438)
14.0
10.1
(25/179)
(31/307)
3.9
(5/128)
1.6
Ono H., 2003
Endoscopic Submucosal Dissection
(ESD)
Courtesy from H. Ono
Endoscopic Submucosal Dissection
(ESD)
Current Recommendation for Gastric EMR in Japan
I
Depth of
Invasion
T1m
UL(-)
≤2cm
>2cm
Histology
T1sm
UL(+)
Any
size
sm1
UL(-/+)
>sm1
<3cm
Any size
Differentiated
Adenocarcinoma
Undiffrentiated
Adenocarcinoma
Japanese concensus for EMR
Extended indications for EMR
Surgery
Clinical trial
Problems encountered in
long-segment Barrett´s Esophagus
• High incidence of multifocal early malignant
lesions
• HGD and early cancer often occur in the
absence of endoscopic abnormalities
(Falk GW et al. Gastrointest Endosc 1999;49:170-6
Seewald S et al. Gastrointest Endosc 2003;57:854-9)
• No reliable staining or other methods
available for detecting these lesions
• High recurrence rate after localized EMR
Results of localized EMR in BE
containing HGIN and IMC
Study
Patients
Ell et. al 2000
May et. al 2002
May et al. 2002
60
50
115
60 EMR
28 EMR
13 PDT
3 APC
2 EMR+ PDT
2 EMR+ APC
1 PDT + KTP
1 PDT + APC
70
32
10
3
EMR
PDT
EMR+PDT
APC
follow-up
(months)
12 ± 8
34 ± 10
34 ±10
Recurr. of Ca/
metachronous Ca
14%
23%
30%
Localized EMR
Circumferential EMR
Complete removal of Barrett´s epithelium by EMR
Seewald et al. Gastrointest Endosc 2003;57:854
Can piece meal EMR ensure
complete removal of Barrett´s
segment ?
MBL-EMR Device
DUETTE TM
MBL-EMR
Pancreatic Abscess
Endoscopic Tripletherapy
- EUS-guided cystenterostomy
- Debridement/Necrosectomy
- Sealing of fistula
EUS-guided Cystgastrostomy &
Endoscopic Necrosectomy
Pancreatic Abscess
Results of Endoscopic Management
Author
Kozarek
Pinkas
Baron
Schöfl
n
1986
1994
1996
1996
Own series 2006
1
1
3
3
37
resolved morbid. Mortality
1
1
3
2
25
0
0
0
0
3
0
0
0
0
0
Acute UGI Bleeding
Mortality
60%
without rebleeding
with rebleeding
50%
40%
30%
20%
10%
0%
0
1
2
3
4
5
6
7
8
Risk Score
Rockall et al. Gut 1996;38:316-21
Current Opinions
• Additional endoscopic treatment after
epinephrine injection reduces further
bleeding, need for surgery, and
mortality
(Meta-analysis of 16 studies including 1673 pts.)
Calvet X et al. Gastroenterol 2004;126:441-50
Rebleeding rate after initial hemostasis with clips
Author
Shimazu, 1993
Soehendra, 1993
Villanueva, 1996
Sabat, 1998
Cozart, 1999
Cipolletta, 1999
Choi, 1999
Nagayama, 1999
Chung, 1999
Cipolletta, 2001
Chua, 2001
Gevers, 2002
Saltzman, 2005
Rebleeding rate
7%
10 %
7%
23 %
4%
0%
0%
15 %
5%
2%
11 %
37 %
15 %
Clipping
Advantages:
• Best suitable for spurting bleed
and visible vessels
• Lower rebleeding rate
• Minor tissue damage
Limitations:
• Chronic ulcer with fibrotic base
• Limited applicability to posterior wall
of the duodenal bulb
Double-balloon Enteroscope
provides therapeutic options
Yamamoto H et al. Gastrointest Endosc 2001;53:216-20
Double-Balloon Enteroscopy for acute and
chronic GI bleeding
European
prospective 2005
Yamamoto et al.
2004
Patients
100
123 (Bleeding 66)
Enteroscopy
147
178
Major complications
none
1.1%
Diagnostic yield
72%
76% (50/66)
Therapeutic
consequence
62%
Hemostasis 12;
polypectomy 1; EMR 1;
Balloon dilation 6; stenting
2
President: Prof. Dr. F. Hagenmüller
www.endoclubnord.com
NOVEMBER 03 - 04, 2006
CONGRESS
CENTRUM
HAMBURG