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Endoscopic submucosal dissection (ESD) was first developed to remove en bloc early gastric neoplasms. Later, this technique was proposed for the management of esophageal and colorectal superficial tumors, and currently ESD is performed routinely in Asia. ESD is indicated for esophageal cancer with no or minimal risk of lymph node metastasis. When the lesions are classified according to the depth of invasion as intraepithelial carcinoma (M1), restricted within the proper mucosal layer (M2), adjacent to or invading but not beyond the muscularis mucosa (M3), invading the submucosal (SM) layer to a depth of one third (SM1) or more than one third (SM2 and SM3) of the layer thickness, then the incidence of lymph node metastasis was reported to be 0%, 0% to 5.6%, 8% to 18%, 11% to 53%, and 30% to 54%, respectively. Therefore, under the 2002 Japan Esophageal Society guidelines for the treatment of esophageal cancer, the absolute indication for endoscopic resection is defined as M1-M2 esophageal cancer as well as two thirds or less extension of the circumference, whereas the relative indication is defined as M3-SM1 esophageal cancer with as much as three fourths or more mucosal defect after resection. ESD with complete resection can only be considered curative for M1-M2 esophageal squamous cell

Feasibility and Effectiveness of Unsedated TransNasal Endoscopy With Chromoendoscopy for Esophageal Cancer Screening Vitor Arantes, Walton Albuquerque, Carlos Alberto Dias, Teresa C. Ferrari, Jose Maria Porcaro, Luiz G. Coelho Alfa Institute of Gastroenterology, Hospital de Clinicas, Federal University of Minas Gerais, Belo Horizonte, Brazil Introduction: Esophageal cancer is usually detected at an advanced stage precluding curative treatment. Alcohol and tobacco abuse and head and neck cancer are risk factors for squamous-cell carcinoma of the esophagus. Transnasal endoscopy (TNE) is routinely practiced in Japan and in European centers. The main advantage is that no sedation is required and therefore patient recovery is faster and costs are lower. In western countries, particularly in North and South America, TNE is seldom practiced and there is not enough evidence about its suitability to these populations. Objectives: To assess the feasibility and effectiveness of TNE with chromoendoscopy for esophageal cancer screening in high-risk population in a Latin American country. Methods: Prospective study. Inclusion criteria: patients with current or past history of head and neck cancer referred to esophageal cancer screening that consented to participate in the study. Exclusion criteria: distant metastasis, nasal surgery, coagulopathy, iodine allergy. Preparation: nasal application of vasoconstrictors and lydocaine. All procedures were performed without sedation with an ultra-thin endoscope (EG530N, Fujinon Fujifilm Co.). Esophageal examination started with white-light and digital chromoendoscopy (FICE), followed by 0.8% lugol chromoscopy. Unstained areas larger than 5 mm, particularly when the pink color sign was positive, were considered suspicious and biopsies were taken. Patient tolerance was registered by the attending endoscopists and an independent observer interrogated the patient afterwards about pain or discomfort applying a visual analogic pain scale. Endoscopic findings and adverse reactions were documented. Results: Between May 2009 until October 2010, 80 patients were included in the study, 80% males, mean age 61 years-old (range: 31 to 89). TNE was feasible in 79 patients (98.8%) and mean exam duration was 17 min (range: 10 30 min). Patient tolerance was rated by the attending endoscopists as excellent in 83% of the subjects, good in 14% and poor in 3%. Examination discomfort was rated by 88% of the patients as absent or minimal, as moderate by 9%, and as intense by 3%. A total of 14 unstained focal lesions were detected: 4 inflammatory, 1 infectious, 3 high-grade dysplasia, 6 squamous-cell cancer. FICE and lugol chromoscopy detected all neoplastic lesions. White-light examination missed one dysplastic lesion. Overall esophageal neoplastic lesions were detected in 10 patients (12.5%), 7 superficial lesions and 3 invasive neoplasia. Adverse reaction: esophageal spasm due to lugol (8%). Conclusions: Unsedated transnasal endoscopy with digital and lugol chromoendoscopy is feasible and effective for esophageal cancer screening in high-risk population in Latin America.

Endoscopic Mucosal Resection (EMR) with a New Solution: 0.4% Hydroxypropyl Methylcellulose (HPMC) Vitor Arantes, Walton Albuquerque, David Lima, Sueli Vilela, Geraldo Lima Jr., Dezimar Duarte, Edgard Benfica, Fauze Maluf Filho, Everson Artifon, Paulo Sakai Background: Hypertonic solutions have been used for submucosal injection during EMR, to produce long-lasting fluid cushion which allows larger ‘‘en bloc’’ resections. HPMC is a low cost drug used for ophthalmic operations. In an experimental study, 0.83% HPMC was injected in the esophageal submucosa producing a long-lasting submucosal cushion, with no adverse effects (Gastrointest Endosc, 2003). In our initial experience 0.83% HPMC proved to be highly viscous which prevented smooth injection using a standard 23G needle. To overcome this limitation a less concentrated solution, 0.4% HPMC, was proposed. Aim: To assess the performance, clinical effectiveness and safety of submucosal injection of 0.4% HPMC for EMR. Methods: Prospective multicenter Phase II study approved by the Ethics Committee of two University Hospitals. Inclusion criteria: Adults with neoplastic superficial lesions larger than 10 mm, intramucosal by endoscopic or EUS criteria, referred to EMR. Collected data: injected volume of HPMC, duration of the submucosal cushion, clinicopathological characteristics of the lesions, ‘‘en bloc’’ and complete resection rates, complications or adverse reactions. Follow-up included clinical exam, endoscopic surveillance and surgical findings (if indicated). Results: A total of 36 patients were enrolled over 12 months (21M, 15F, mean age 64 years). Site of the lesions: stomach 14, colon 11, rectum 5, esophagus 3, duodenum 3. Macroscopic type: 0IIa 20, 0Is 8, LST 4, 0IIb 2, 0IIc 2. The mean size of the resected specimen: 20.4 mm (10-60 mm). EMR technique: free-hand 27, strip biopsy 6, ESD 2, cap-EMR 1. The mean injected volume of 0.4% HPMC was 10.7 cc (4-35cc). After the injection of HPMC, submucosal fluid cushion lasted a mean of 27 min (9-70 min). The ‘‘en bloc’’ and complete resection rates were 44.4% and 89%. Complications: immediate bleeding in five patients (13.8%) managed by clipping and APC, no transfusion. One case of esophageal perforation (2.7%) was surgically managed. Pathology report: intra-epithelial neoplasia 27, intramucosal cancer 7, submucosal cancer 2, carcinoid 2, hyperplastic 2. No adverse events caused by the use of the solution were noted in the clinical follow-up. Twenty-six patients (72.2%) received endoscopic control (mean 2.2 months). Three patients were surgically managed. No local adverse reactions were observed at the sites of EMR. Residual neoplasia was detected in four cases, who received additional EMR. One patient had recurrence of the lesion and was referred to surgery. Conclusions: The 0.4% solution of HPMC proved to be safe and effective for creating a long-lasting submucosal fluid cushion during EMR of large lesions.