early rectal cancer: i can do it better · t1b vs. 1a eus best modality ln+ eus-fna + ct/mr (dwi)...
TRANSCRIPT
![Page 1: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/1.jpg)
Reiner Wiest
UVCM, Inselspital Bern
Early rectal cancer:
I can do it better
![Page 2: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/2.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Fair duellation ?
One endoscope
One working channel
„single arm bandit“
![Page 3: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/3.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
The endoscopists weapon...............
Near Focus Retro-
flexion
NBImagnification
![Page 4: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/4.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endoscopic submucosal dissection
80 x70 mm
Tubulovillous Adenoma
En-bloc
R0-resection
HGD
![Page 5: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/5.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Better in terms of
Safety: morbidity and mortality
Oncological outcome
Quality of life
Costs
![Page 6: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/6.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Cost - advantages for ESD
No operation theatre
No general anaesthesia
.........
cases Procedure Time
ESD/ TEM
Hospitalisation
ESD/TEM
Park et al 30/33 84+/-51 116+7-58 3.6+/-1.2 4.8+/-3.3
Kawaguti et al 11/13 133+/-60 150+/-66 3.8+/-3.3 4.0+/-1.7
Jung et al. 48/ 23 n.s. 2.3+/-1.2 5.8+/-1.8
....................
Park et al. Endoscopy 2011; Kawaguti et al. Surg Endosc. 2014; Jung et al Surg Endo 2014
![Page 7: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/7.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
no lymph-invasion
no (only low grade) budding
< 1000 mikrometer invasion
Oncological approach – outcome in ESD
No need for oncological full thickness resection
when no risk factor for LN-positivity
(in absence of poor differentiation)
Do you know this before intervention ?
diagnostic accuracy pre-operatively by
chromoendoscopy, near-focus, high-definition, EUS...
is suboptimal
![Page 8: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/8.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD
is the best
DIAGNOSTIC MEASURE
Avoiding overtreatment
![Page 9: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/9.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 10: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/10.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endoscopic resection does not decrease outcome
after subsequent surgery
Overwater, Gut 2017
602 pts. (263 primary vs. 339 secondary surgery)
34 recurrences (5.9%)
No differences in
Presence lymph-node positivity (OR 0.97) 0.49-1.43
Recurrence (HR 0.97) 0.41-2.34
Endoscopic En-bloc resection
of a possible T1 CRC without evident signs of deep invasion
justified
in order to prevent surgery of low-risk T1 CRC
in a significant proportion of patients
![Page 11: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/11.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Selection of early rectal cancer for endoscopic resection
Risk of deep sm-invasion
Homogenous
No NBI-risk-
features
< 1%
> 30%With NBI-
risk features
+ depressedNo
n-
Gra
nu
lar
Gra
nu
lar
Lateral Spreading Tumor (LST)
![Page 12: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/12.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
NBI-magnification: classification- systemsS
an
o-K
lassif
ikati
on
Hir
os
him
a-K
lass.
Typ
2
Typ
3a
Typ
3b
Typ
B
Typ
C1
Typ
C2
Ris
kfo
rd
ee
p
sm
-in
filt
rati
on
Sensitivity > 70% with Specificity > 90%
e.g. Typ 3 b / Typ C2
rather no candidate for ESD
![Page 13: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/13.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endoscopic full thickness resection (FTRD)
![Page 14: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/14.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
15 mm T1sm1-L0V0G2- R0
Endoscopic full thickness resection (FTRD)
![Page 15: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/15.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Comparison of resection techniques
ESD vs. Surgical Methods
(no randomized trial, no meta-analysis)
Backes, Am J Gastroenterol 2017, Lee, Ann Surg 2017, Kiriyami Endoscopy 2011, SaitohDig Endoscopy 2016, Kim DigDisSci 2015, Higuti Jpn Soc Coloproct 2006
ESD TEM/TAMIS
Local Recurrence 0 - 3.4% 1-6%
Quality pathology
specimen
+++ +
(fragmentation 5%)
Complication rate + ++
![Page 16: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/16.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Safety: ESD vs. surgical approach
Complication rate
(%)
ESD TEM/TAMIS
Jung et al. 4.3+/-1.2 5.8+/-1.8
Arezzo et al. 8.0+/-2.2 8.4%+/- 4.2
Clancy et al. 3.3+/-1.3 6.9+/-3.2
..............
ESD
is
truely minimal invasive
AND
organ preserving
![Page 17: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/17.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Quality of life - advantages for ESD
62 ESD vs. 32 LAC in T1 rectal cancer
Questionaires for quality of life POD1 and POD 14
POD1POD14
Nakamura et al. DigDis2017
ESD achieves excellent results
in quality of life after local resection
in early rectal cancer
![Page 18: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/18.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
GII 2013
T2N1M0
Neoadjuvante RCTx
Refusal for
oncological surgey
Combining techniques: ESD plus TAE
![Page 19: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/19.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Combining TAE and ESD
Yang et al. GII 2013
T1a/m1 L0V0G2
T1-sm2 -L0V0G2
![Page 20: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/20.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endoscopic TAMISMcLemore et al. Gastroenterology 2013
![Page 21: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/21.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
SUMMARY: endoscopic approach for rectal neoplasia
easy access, wide/ great visibiliy/resolution
best diagnostic measure
truely minimal invasive
keeping quality of life optimal
preserving organ + functionality
Low in cost
is the WINNER
![Page 22: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/22.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 23: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/23.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ADD ON ADD ON ADD ON
![Page 24: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/24.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Complication rates
ESDTEM TAMIS
Depends on comorbidities, age, medication....
![Page 25: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/25.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Which lesions benefit most? ESD better suited for ?
• SM1, no lymphovascular invasion, no budding
25
Fuccio L, Gut (Online First 2018)
Reaching to anocutan line
Large surface area (e.g. > semicircular
More superficial (Tis, T1a) where
no full thickness is oncologically
![Page 26: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/26.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
How accurate pre-operative prediction of risk
factors
Increased risk of deep submucosal infiltration:
- irregular surface/ non-granular LST
- depressed or pseudo-depressed morphology
Then full-thickness not needed !!
![Page 27: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/27.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 28: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/28.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endoscopic resection does not decrease outcome
after subsequent surgery
Overwater, Gut 2017
-> attempt for an en-bloc resection of a possible T1 CRC without
evident signs of deep invasion seems justified in order to
prevent surgery of low-risk T1 CRC in a significant
proportion of patients.
![Page 29: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/29.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
29
-> attempt for an en-bloc resection of a possible T1 CRC without
evident signs of deep invasion seems justified in order to
prevent surgery of low-risk T1 CRC in a significant
proportion of patients.
![Page 30: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/30.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Reliable assessment of depth of invasion
![Page 31: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/31.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
1 : 100
• 1 ESD expert enough to resect rectal lesions discovered by
100 endoscopist performing screening colonoscopies all
day
![Page 32: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/32.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 33: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/33.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Risk of LN – in dependency on sm-invasion
0-3% 8-10% 23-25%
![Page 34: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/34.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
EUS most accurate method
To differentiate T1 from T2
![Page 35: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/35.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Higher LN-risk
![Page 36: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/36.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Risk LN pos
Granular > Non-granular
Risk LN pos in Non-granular
With nodule and/or depressed > without nodule
![Page 37: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/37.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 38: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/38.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 39: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/39.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 40: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/40.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
FTRD when sm-positivity suspected......
![Page 41: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/41.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD/
TEM
cases En-bloc
ESD/TEM
R0
ESD/TEM
Recurrence-
rate
Park 30/33 97%/ 100% 97%/ 97%
Kawaguti 11/13 82%/ 84% 82%/ 84%
Verra 89%/ 99% 74%/ 89%
Arezzo 87%/ 98% 75%/ 88% 2.6%/5.2%
![Page 42: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/42.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 43: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/43.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 44: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/44.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 45: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/45.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 46: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/46.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 47: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/47.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 48: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/48.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 49: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/49.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 50: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/50.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 51: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/51.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 52: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/52.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 53: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/53.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
p-EMR ESD TEM/TAMIS
Local Recurrence 3.4 %
10-23.5%
0-3% 6%
Quality of the
pathology
specimen
--- +++ + (7% R1, 5%
fragmentation)
Impact on rescue
surgery
0 0 ---
if full thickness
resection
Duration of
procedure
+ +++ ++
Cost + ++ +++
Complication rate + ++ +++
![Page 54: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/54.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD advantages and strength
- Best diagnostic/staging procedure
- Surgical approach in case being non-curative not hampered
- Organ-anatomy-function sparing
- Better patient quality of life
![Page 55: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/55.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
...procedure needs to be....
SAFEno
perforationno
major bleeding
HIGH QUALITYR0 en-bloc
![Page 56: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/56.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD: What do Limits depend on ?
Expertise
Expertise
Expertise
![Page 57: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/57.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD: Who is an Expert ?
Naohisha Yahagi Reiner Wiest= EXPERT
Pioneer in ESD
Inventor of Dual-Knife
ESD > 12 years
Daily ESD, difficult cases
> 500/year
Training the trainer
![Page 58: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/58.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Duodenum: most challenging-> rarely ESD done (except Experts) large lesion in bulb
45×30mm, adenocarcinoma tub1,
T1a(M),Ly0,v0,HM0,VM0Courtesy Prof. N. Yahagi
Tokio, Keioto University
![Page 59: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/59.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Esophagus: circumferential extensive ESD
in Barrett C11M12 with multi-level HGD + carcinoma
14 cm long resected specimen incl. adenocarcinoma
T1a(M),Ly0,v0,HM0,VM0 Wiest R, Caca K et al
SGG 2017
![Page 60: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/60.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Size/Area cm2
Location
Pre-treatment:
Fibrosis..............
Lesion-Limits for ESD ?
For Expert
Not
Really
limiting
Can be
difficult/
limiting
![Page 61: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/61.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
less time consuming to learn: easy and safe
CE-market currently for lower GI tract
Full thickness resection device (FTRD)
Limits: lesion size = cap length 23 mm
Subepithelial Tumors (rather/more diagnostic)
Pre-treated pre/- early malignant lesions
![Page 62: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/62.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
....procedure needs to make....
SENSE
![Page 63: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/63.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD and Full-thickness only
make sense in case of
only then local resection is curative
Absence of lymphangio-invasion
No lymph node positivity
![Page 64: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/64.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
„Expanded“ criteria for ESD in stomach
Equal to „normal“ guideline indications for
overall survival, recurrence-rate
Gotoda et al. Gastric Cancer 2000; Br J Surg 2010
Oncological Limits for Gastric ESD
![Page 65: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/65.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Hölscher A et al. Ann Surg 2009
Rate of LN-positivity in early gastric cancer
Diagnostic accuracy
T1b vs. 1a EUS best modality
LN+ EUS-FNA + CT/MR (DWI)
NPV suboptimal
(55 - 90 %)
![Page 66: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/66.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endoscopic full-thickness resection + sentinel LN-navigation
+ laparoscopic closure
Hybrid: endoscopic AND laparoscopic approach
Kim et al. ClinEndos 2017
Optimized T- and N- staging
= best oncological decision making
= treatment = prognosis ?
![Page 67: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/67.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
SERVICE
Worth Pushing Limits
SAFE
training-> expertise-> ESD/FTR are
feasable for most early cancer lesions in upper GI tract
SENSE
Main limitation pre-operative accuracy for LV/LN+
combined endoscopic + laparascopic + sentinel LN-dissection
Limitations or Triple-S
for ESD/full thickness resection
![Page 68: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/68.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
„Once you accept your limits
you go beyond them“
Albert Einstein
![Page 69: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/69.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Park JY, Kim YW, Ryu KW, et al. Assessment of
laparoscopic stomach preserving surgery with
sentinel basin dissection versus standard
gastrectomy with lymphadenectomy in early
gastric cancer-a multicenter randomized phase
III clinical trial (SENORITA trial) protocol. BMC
Cancer 2016;16:340.
![Page 70: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/70.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Ahn et al. GIE 2011
Extended criteria for gastric ESD
![Page 71: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/71.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD success in dependency on size and location
75% of the circumference
independent risk factor for perforation
(OR = 7.37, 95%CI: 1.45-37.4, P = 0.016)
Noguchi M et al. WJG 2017
Lesion size < 49 mm > 50 mm
En-bloc-rate 89.4% 85.7%
R0-rate 70.8% 40.5%
Proc. time/min 92+62 217+120
Complications 9.2% 17.6%
Dumoulin et al. Endoscopy Int Open 2016
![Page 72: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/72.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Limitations or Triple-S
for ESD/full thickness resection
SERVICE
Worth Pushing Limits
SAFE
training-> expertise-> ESD/FTR are
feasable for most early cancer lesions in upper GI tract
SENSE
Main limitation pre-operative accuracy for LV/LN+
combined endoscopic + laparascopic + sentinel LN-dissection
![Page 73: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/73.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Summary - Outlook
ESD
needs to be safe
expertise of the operateur is most important
training is essential and quality criteria needed
FTRD
soon routine and „easy“ to use
Oncological strategy / diagnostic accuracy
and patient-oriented
![Page 74: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/74.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Triple S-
Surgical candidates:
Consider ESD/FTRD as diagnostic tool
Inoperable patients:
Individual decision
After optimal diagnostic workup
![Page 75: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/75.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Diagnostic accuracy
T1b vs. 1a EUS best modality
LN+ EUS-FNA + CT/MR (DWI)
NPV suboptimal
(< 90 %)
![Page 76: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/76.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Cases/Erfahrung 1-24 25-50 >50
En-bloc-rate 60% 88% 96%
R0-rate 48% 76% 84.5%
Perforationen 1.3% - -
Probst et al. Endoscopy 2012
ESD: complication rate and training
![Page 77: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/77.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
What do Limits for ESD depend on- else ?
Patient: condition, medication, fitness, wishes
Local infrastructure: assistance
Case-Load of center
![Page 78: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/78.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Water Pressure Method
Yahagi N et al. Endoscopy. 2017
ST hoodFuji film medical ,
JAPAN
Traction
Method
Device
Patient
Position
![Page 79: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/79.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Full thickness resection device (FTRD)
![Page 80: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/80.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Oncological Limits for ESD
Pre-Operative diagnostic accuracy ?
Aim of treatment ?
Risk of LN-Positivity in dependency on infiltration depth
![Page 81: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/81.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 82: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/82.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Oncological Indication for Esophageal ESD
Squamous Ca
HGD
mucosal cancer
Adeno/Barrett Ca
HGD
mucosal cancer
< 100 mm
![Page 83: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/83.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Morbidity and Mortality from surgery ?
1-4 % dependend on patient, location, tumor....
![Page 84: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/84.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Quality criteria ESD
Histology for specimen
Lateral and vertical margin!
Desmin-staining for L.musc.mucosa->
From here on grading sm since > 500 mikrometer in
Victoria blue (or D2-40-staining) better vascular invasion
![Page 85: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/85.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
PULS of gastric ESD
Non-curative ESD – Definition - consequences
Positive vertical margin
Undifferentiated grading
Lymphangioinvasion
Sm-positivity (> sm 1)
High risk of recurrence and/or LN-positivity
Gastrectomy with LN-dissection
Deep margin
Predicts 10y
T1 EAC-Barrett
Leggett et al. ClinGastroHepatol
![Page 86: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/86.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
344 ESD for early gastric cancer
43 patients operated due to:
residual mucosal cancer (R1)
Mucosal cancer larger than 3 cm
submucosal cancer
regardless of size or margin
When is ESD for early gastric cancer curative ?
Ryu et al. Annals Surg Oncol 2007
< 500 mm sm invasion
< 30 mm size
NO (0/39)
LN+
![Page 87: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/87.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD for undifferentiated early gastric cancer ?
Abe et al. Endoscopy 2013
![Page 88: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/88.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Sentinel-lymph-node stratetgy to optimize
Oncological accuracy when aiming for curation
NPV 67-94%
Meta-Analysis
B. Filip et al. SurgEndosc 2014
At best combination radioactive colloid (e.g. 99Tc)
dye (e.g. ICG)
NPV 90%
Meta-Analysis
Wang et al. Ann Surg Oncol 2012
![Page 89: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/89.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Goto, Yahagi et al. Transl Gastro Hepatol 2016; Cho et al. Endoscopy 2011
Endoscopic full-thickness resection + sentinel LN-navigation
+ laparoscopic closure and
NEWS
![Page 90: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/90.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
GERDx System; G-SURG
GmbH, Seeon-Seebruck,
Germany
![Page 91: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/91.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD: Traction-method
![Page 92: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/92.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Endolifter (Olympus, Tokyo)
![Page 93: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/93.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Together
Combined
Laparoscopic plus endoscopic
NEWS procedure
![Page 94: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/94.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
expanded criteria von Gotoda gelten in Japan als Standard und sind auch mit
überlebensdaten validiert, d.h. Schneiden wirklich gut ab und sind allgemein (auch im westen
zentren) anerkannt. En-bloc resektion in den grösseren Serien (aus Japan) oft und
meist der einzige prädiktive Faktor für langfristige nachhaltige Kuration, dh. Dann exzellente
Langzeitprognose (z.b. Isomoto H Gut 2009; 58; 331ff). Dies spricht eben wiederum klar für
risiko sicher entscheidend und meines wissens die Literatur kontrovers: z.b. Von Hölscher
AH et al. Ann SUrg 2009, 250:791 auch bei T1-m3 Tumoren LK-positivität berichtet (nach
Gastrektomie mit Lymphadenektomie)! Dagegen bei m1/2 nie und auch alle mukosalen
Karzinome < 2 cm alle ohne LK-positivität (wobei die Arbeit leider keinen L-status im
Präparat angibt, wahnsinn). Interessant in dem Zusammenhang der Ansatz der Asiaten: nach
ESD bei Hochrisiko-features für LK-positivität laparoskopisch eine Lymphadenektomie
machen und falls eben L0 dem Patienten die Gastrektomie zu ersparen mit vielversprechendne
Daten (die zwar aus 2010 sind z.b. Kim YH et al. Korean J Gastrointest. Endosc. 2010:
96) hab aber nichts neues mehr gesehen); erscheint mir aber (als nicht -chirurg) ein
![Page 95: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/95.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 96: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/96.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Hölscher A et al. Ann Surg 2009
Rate of LN-positivity in early gastric cancer
Basically (very low or) NO risk of LN-postivity when
G1 or papillary histopathology
M1 or m2 depth and < 2 cm
Sm1 but < 1 cm
![Page 97: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/97.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Rate of LN-positivity in early gastric cancer
role of tumor type
Hölscher A et al. Ann Surg 2009
![Page 98: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/98.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Rate of LN-positivity in early gastric cancer
role of tumor size
Hölscher A et al. Ann Surg 2009
Risk of LN+ starts already in m3- tumors
Particularly if
G3/G4
> 20 mm in size
![Page 99: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/99.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 100: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/100.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 101: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/101.jpg)
ESD: Case Load in Germany - Expert-Hands ?
![Page 102: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/102.jpg)
New Suturing Technique Using Clip and Line
Yahagi N et al. GIE 2016 , Nishizawa T, Yahagi N et al. GIE 2017
![Page 103: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/103.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Large Duodenal Lesion Located at 2nd Portion
![Page 104: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/104.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
7 months after
ESD
![Page 105: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/105.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Fullthickness upper GI-tract
Device - method
![Page 106: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/106.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 107: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/107.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Duodenal Adenoma + Malignancy: Chromoendoscopy
![Page 108: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/108.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 109: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/109.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Tubular adenocarcinoma in adenoma
0-Ⅱa, 57×42mm, tub1>>tub2
pTis, ly0, v0, pHM0, pVM0
![Page 110: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/110.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Naohisha Reiner
What do Limits
for ESD/FTRD depend on ?
Expertise/Training
Equipment
Local Setup
Limit ?
very individual
![Page 111: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/111.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
ESD better than EMR
Size: unlimited in area
(vs. Snare-size for EMR)
Depth: highly controlled up to full sub-mukosa
(vs. Uncontrolled in EMR)
higher rate of
en-bloc, R0, local-recurrence
Meta-Analyse Lian J GIE 2012
![Page 112: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/112.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Indikationen FTRD Colon
![Page 113: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/113.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 114: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/114.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 115: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/115.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 116: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/116.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 117: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/117.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
![Page 118: Early rectal cancer: I can do it better · T1b vs. 1a EUS best modality LN+ EUS-FNA + CT/MR (DWI) NPV suboptimal (55 - 90 %) SGVC 2018 Inselspital Bern: UVCM –Klinik für Viszerale](https://reader035.vdocument.in/reader035/viewer/2022070923/5fbb6d17bfdbb64112692093/html5/thumbnails/118.jpg)
SGVC 2018
Inselspital Bern: UVCM – Klinik für Viszerale Chirurgie und Medizin
Gastric polyps:
Which are not mucosal ?
Diagnostic accuracy – Gastric
EUS: T1/2 vs. T3/4: sens 86%, spez 91%
N-positivity: sens 69%, spez 84%
Mocellin S et al. GIE 2011