Endoscopic submucosal dissection with insulated-tip knife for large mucosal early gastric cancer: a feasibility study (with videos)

Background: According to clinicopathologic studies, differentiated-type mucosal early gastric cancers without ulcer or ulcer scar have little risk of lymph-node metastasis, irrespective of tumor size. However, patients with large mucosal early gastric cancer have been subjected to surgery because conventional EMR methods could not resect large tumors en bloc. Objective: To evaluate the feasibility and the efficacy of endoscopic submucosal dissection for treatment of early gastric cancers larger than 3 cm in diameter. Design: Case series study. Setting: Referral cancer center. Patients: A total of 30 consecutive patients were enrolled with the following characteristics: diagnosis of differentiated-type early gastric cancer larger than 3 cm, lack of ulcerative change, no endoscopic evidence for submucosal invasion, and no evidence of lymph-node or distant metastasis (22 men and 8 women; median age, 69 years; median tumor size, 40 mm). Interventions: Tumors were resected by endoscopic submucosal dissection with an insulated-tip knife. Main Outcome Measurements: Complete resection, complication rate, and operation time. Results: Complete resection was obtained in 23 of 30 cases (77%). Complications included hemorrhage (n = 4), perforation (n = 1), and pyloric stenosis (n = 1), but no severe complications occurred that required surgery or that led to major morbidity. Complete resection and complication rates improved in the last 10 cases (90% and 0%, respectively), though operation time was not shortened. Limitations: Small sample size and lack of controls. Conclusions: Endoscopic submucosal dissection when using the insulated-tip knife is feasible and efficacious for selected patients with mucosal early gastric cancer larger than 3 cm.