Purpose In the prospective study 02/96 on primary GI lymphoma, we have collected data on histology, clinical features, and treatment results. In particular, in stages I and II localized primary gastric lymphoma (PGL), our objectives were to reduce treatment intensity and to confirm our hypothesis from study 01/92, which maintained that an organ-preserving approach is not inferior to primary surgery. Patients and Methods Patients receiving radiotherapy and/or chemotherapy were stratified for histologic grade, stage, and whether surgery had been carried out or not (as decided by each participating center). Patients with aggressive PGL received six cycles of CHOP-14 (cyclophosphamide, doxorubicin, vincristine, and prednisone) followed by involved-field radiotherapy (40 Gy). Patients with indolent PGL (including patients experiencing treatment failure with antibiotic therapy for Helicobacter pylori) were treated with extended-field radiotherapy. The volume depended on stage. The irradiation dose was 30 Gy, followed by a boost of 10 Gy (the latter omitted after complete resection) to the tumor region. Results Seven hundred forty-seven patients were accrued. Of these patients, 393 with localized PGL were treated with radiotherapy and/or chemotherapy only or additional surgery between December 1996 and December 2003. The survival rate at 42 months for patients treated with surgery was 86% compared with 91.0% for patients without surgery. Conclusion In this nonrandomized study (02/96), we reproduced the previous results of study 01/92 showing no disadvantage for an organ-preserving treatment. Therefore, primary stomach resection should be questioned.

Background and study aims: Endoscopic resection is the standard treatment for superficial esophageal cancer. Data on early adenocarcinoma (EAC) are widely restricted to endoscopic mucosal resection (EMR), whereas large studies have been published on endoscopic submucosal dissection (ESD) for early squamous cell carcinoma (ESCC). ESD has potential advantages regarding en bloc and R0 resection rates, which have been demonstrated for ESCC. However, studies have failed to confirm these advantages in EAC. The aim of this study was to investigate the efficacy of ESD in early esophageal cancer. Patients and methods: A total of 111 early esophageal cancers (87 EACs and 24 ESCCs) were resected by ESD at a German tertiary referral center. A total of 60 EACs were resected within Barrett’s segments ≤ M3. Resection rates, complications, and follow-up data were recorded prospectively. Results: En bloc resection rates were 95.4 % for EAC and 100 % for ESCC (P = 0.575), and R0 resection rates were 83.9 % and 91.7 %, respectively (P = 0.515). The R0 resection rate was higher in Barrett’s ≤ M3 vs. > M3 (90 % vs. 70.4 %; P = 0.029). The curative resection rate was 72.4 % for EAC vs. 45.8 % for ESCC (P = 0.026). Endoluminal recurrence was observed in 2.4 % of EACs (8 % in Barrett’s > M3, 0 % in Barrett’s ≤ M3), and 0 % of ESCCs. Complications included strictures (11.7 %) and bleedings (0.9 %), but no perforation. Disease-specific survival was 97.7 % (EAC) and 95.8 % (ESCC), and overall survival was 96.6 % (EAC) and 66.7 % (ESCC) over a mean follow-up period of 24.3 months and 38.0 months, respectively. Conclusions: ESD was shown to be a safe resection method, achieving high R0 resection rates in both EAC and ESCC. Recurrence rates were low. To improve R0 resection within long Barrett’s segments, diagnosis of the lateral extension of the lesion needs to be improved.

Background and study aims Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer (EGC) fulfilling guideline resection criteria or the expanded resection criteria in Asia. It is unclear whether the expanded criteria can be transferred to European patients, and long-term follow-up data are lacking. The aim of this study was to evaluate long-term follow-up data after ESD of EGCs in Europe. Patients and methods Patients with EGC who underwent ESD were included in this single-center study at a German referral center. Patient and lesion characteristics, procedure characteristics, and follow-up data were recorded prospectively. Results A total of 179 patients with 191 EGCs were included over a period of 141 months, with 29.6 % of lesions meeting guideline criteria and 48.6 % meeting expanded criteria. The en bloc resection rate was 98.4 % for guideline criteria and 89.0 % for expanded criteria lesions (P = 0.09), and the R0 resection rate was 90.2 % and 73.6 %, respectively (P = 0.02). The main reason for the expanded criteria was a lesion diameter > 20 mm (81.6 %). Complications: perforation 1 %, delayed bleeding 6.3 %, stricture 2.1 %, procedure-related mortality 1.1 %. Local recurrence rate was 0 % for guideline criteria and 4.8 % for expanded criteria lesions (P = 0.06), and the rate of metachronous neoplasia was 15.1 % and 7.1 %, respectively (median follow-up 51 and 56 months, respectively); 92.9 % of metachronous neoplasia were treated curatively with repeat ESD. One patient developed lymph node metastasis after ESD of a submucosal invasive expanded criteria lesion. Long-term-survival was comparable between the two criteria (P = 0.58). No gastric cancer-related death was observed in either group. Conclusions ESD can achieve high rates of long-term curative treatment using the expanded criteria in EGCs in Western countries. We recommend ESD as treatment of choice not only for guideline criteria EGCs but also for intramucosal nonulcerated EGCs regardless of their diameter.

Background and study aims Endoscopic resection is a curative treatment option for large nonpedunculated colorectal polyps (LNPCPs). Endoscopic submucosal dissection (ESD) allows en bloc resection but ESD experience is still limited outside Asia. The aim of our study was to evaluate the role of ESD in the treatment of early rectal neoplasia in a European center. Patients and methods 330 patients referred for endoscopic resection of rectal LNPCPs were included prospectively. Results ESD was performed for 302 LNPCPs (median diameter 40 mm). Submucosal invasive cancer (SMIC) was present in 17.2 % (n = 52). SMIC was associated with Paris type (54.5 % among type 0-Is lesions, 100 % of 0-Is-IIc type, 0 % of 0-IIa, 14.9 % of 0-IIa-Is, and 59.3 % of 0-IIa-IIc type; P < 0.001) and with surface pattern (71.4 % among nongranular plus mixed surface lesions, 17.9 % of lesions with granular surface and nodule ≥ 10 mm). For SMICs, resection rates were en bloc 81.4 %, R0 65.1 %, and curative 30.2 %. Curative resection rate improved from 13.6 % to 47.6 % over the study period (P = 0.036). The reason for 83.3 % (25/30) of noncurative resections was submucosal invasion exceeding 1000 µm. For benign lesions (n = 250, 82.8 %), the R0 resection increased from 55.2 % to 84.8 % over the study period (P < 0.001). Recurrence rate was 4.8 %, bleeding rate 5.2 %, and perforation rate 0.8 % (all complications managed conservatively). Median follow-up was 35 months. Conclusions The majority of rectal LNPCPs are benign lesions. ESD offers high R0 resection and low recurrence rates but EMR may be appropriate. In lesions with a risk for SMIC, ESD should be offered to achieve R0 resection. Despite high rates of R0 resection the curative resection rate of ESD for rectal SMIC is < 50 %. Pretherapeutic lesion selection needs improvement.

Background and study aims The ideal treatment strategy for rectal neoplasia extending to the dentate line (RNDL) is not well defined. Endoscopic mucosal resection (EMR) and submucosal dissection (ESD) compete with surgical techniques such as transanal endoscopic microsurgery (TEM). Non-Asian data and prospective data on ESD are lacking. The study aim was to evaluate the role of ESD in treatment of RNDL in a Western center. Patients and methods Eighty-six patients with rectal adenomas were included. ESD was performed in 86 rectal adenomas including 24 RNDLs (27.9 %) and 62 lesions distant from the dentate line (72.1 %). Results En bloc resection rate was comparable (91.7 % vs. 93.5 %, P = 0.670) between ESD for RNDL and non-RNDL. R0 resection rate was significantly lower in ESD for RNDL compared to that for non-RNDL (70.8 % vs 88.7 %; P = 0.039), but most non-R0 resection was unclear margin (Rx) and was not obvious positive margin (R1). Accordingly, the recurrence rate after ESD for RNDL (4.5 %) was not statistically different from that for non-RNDL (0 %, P = 0.275) and was lower than that previously reported for EMR. Median procedure time was 127 vs. 110 minutes (P = 0.182). Risk of delayed bleeding (20.8 % vs. 0 %, P = 0.001) and postinterventional pain (33.3 % vs. 14.5 %, P = 0.07) increased in RNDL cases, but they were managed conservatively. Incidence of stricture (4.2 % vs. 1.6 %, P = 0.483) and perforation (0 % vs. 1.6 %, P = 1.000) were similar. Conclusions ESD is a feasible and safe resection technique for RNDLs. A randomized controlled trial comparing ESD to other methods (EMR or transanal surgery) is warranted.

Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of early-stage gastrointestinal neoplasms. Adequate submucosal exposure is one of the most significant factors related to an effective and safe dissection. The aim of this systematic review was to evaluate the efficacy and safety of various methods that assist traction during ESD of precancerous and early-stage neoplastic lesions of the gastrointestinal tract. We performed an electronic search of the MEDLINE and the Cochrane Controlled Trials Register databases for relevant studies published up to May 2019. Trials exclusively recruiting patients undergoing ESD for superficial gastrointestinal cancer were considered eligible for inclusion. Thirty-three articles including 3,134 patients met the inclusion criteria. The studies evaluated different approaches for widening the endoscopic view, including magnetic anchor-guided ESD (3 studies), use of a second endoscope (5 studies), clip-involving technique (21 studies), and miscellaneous methods (4 studies). Among them, only 6 were randomized controlled trials evaluating different approaches. Overall, the implementation of methods that assist traction during ESD significantly improved the operating time and R0 resection rate and decreased the rate of complications (bleeding and perforation). Interventions that assist traction seem efficacious in improving tissue traction, thus facilitating ESD performance.