All right, guys, you're in the home stretch. For those of you that don't find this absolutely fascinating, and love it like I do, hang on, we're almost at the end here. We're going to discuss Endoscopic submucosal dissection as well as some of the ablative therapies. When we apply them, how we apply them, who we apply them in. And then wrap everything up for you here at the end. So you can walk away and have a good understanding of how we manage these patients with early stage esophageal cancer endoscopically. As well as the TN staging that we can provide echo endoscopically. I'm going to touch base briefly on Endoscopic Submucosal Dissection or ESD. This is a technique that is definitely not as commonly performed here in the United States but it's definitely catching on and gaining foothold. It's preferred to EMR for lesions that are T1b. So, tissue and new plastic tissue that is now invading into the submucosa is what we are looking at whenever we are talking about ESD for these patients. The technique of ESD is similar and here you can actually see where they are marking the abnormal area which is a sort of middle darker orange tissue. You could see them injecting and the fluid underneath to form almost a little bubble barrier and this is exactly what we do with EMR as well, but I wasn't able to show you in the previous images. And then essentially what is done is it's essentially dissection in real time endoscopically using your marks and using your injection to lift that tissue off the muscular layer beneath it. The efficacy of ESD in Japan, where it is used quite often for squamous cell carcinoma. Now remember, outside the United States, when we talk about esophageal cancer is squamous cell the best majority of the time. Only in the United States are we talking about Adno Carcinoma. So in Japanm ESD for squamous cell cancers has shown up to 100% en bloc resection and 80% curative resection. When it's compared to EMR for squamous cell, ESD had a higher en bloc resection rate a 100 versus 53 and a lower recurrence rate. Essentially, you are performing what's closer to a surgical procedure with more accuracy and more precision when you're talking about ESD when compared to EMR. Because it is dissection under direct visualization. In addition, whenever we're talking about ESD compared to EMR, we're going deeper into the esophageal wall as well. And so if there is any micro-metastasis or small foci of disease that may be hiding out or may have gone through that we didn't realize, you're getting that out more effectively and more completely with ESD than EMR. Complications of ESD are very similar to EMR. We quote bleeding in 5 to 10% of patients. Perforation is higher is 2 to 5% rather than less than 1% for EMR. But again, you're going deeper into this esophageal wall, so that is to be expected. Stricture formation is 5% to 17.2%, depending on which study you see. Ablation goes along with any endoscopic therapy that we offer, because you have to address the remaining tissue that is remaining, since our thought it that is what's predisposed the person to developing cancer in the first place. So we provide ablation therapy with patients who have Barrett's Esophagus with low grade or high grade displasia, patients that have intra-mucosal carcinoma, sort of the T1a lesions. And we've put it in combination with resection for high grade displasia or intra-mucosal carcinoma. Or if you have somebody that just had a low grade dysplasia, or we can prove by that as monotherapy, just to address the Barrett's tissue to prevent cancer from forming. Ablation techniques include APC, heater probe, and RFA. All are very superficial, and they have limited roles for that reason as monotherapy. When you're asking or you're taking about curative intent of intra-mucosal carcinoma. Any time we have carcinoma, we do not employ therapy as monotherapy, we always do it in combination with a resection. PhotoDynamic Therapy again is also used in combination with resection or a second ablation modality. Data from monotherapy is pretty limited and that's why we tend to use it as second ablative modality. In one study looking at squamous cell sarcoma patients, 87% eradication was reported but there was an 18% recurrence rate. Stricture rates are as high as 33% with photodynam therapy. Cryotherapy is something that we employ particularly in areas that are nodular. So like I said, whenever we apply RFA or our heat therapies, we have what almost looks like a baseball bill hat that we place against the mucosa to deliver the thermal inablation therapy to. Whenever you have nodular areas you don't get good tissue apposition between your probe In between the tissue. And so we looked at cryotherapy for managing those patients. Efficacy when we're using it in conjunction with resection for HGD or T1a lesions show that it downgraded or eliminated neoplasia in 90% of patients. Complications include chest pain, dysphagia, very rarely perforation. So now that we're at the end of what we were talking about, let's sort of summarize and see what you should be able to take away at the end of going through all of this. So, Esophageal cancer is rare. It represents maybe 1% of the new cancers that are diagnosed in the United States. Endoscopic therapy is an attractive option compared to surgery for certain cases, and for a very specific population. Disease Depth is absolutely critical when talking about prognosis, when talking about staging, and when talking about therapeutic options. EMR can be used for staging and curative intent. You should know the high risk features for metastatic disease, because that'll be important to your patients, as well as your surgical colleagues. Curative EMR is offered in up to T1a disease. And curative ESD can be offered in up to T1b. Now let's revisit those questions that we mentioned at the beginning of the lecture, and see if we can now pick out what the answers are. Number 1, Application of endoscopic therapy for the management of esophageal cancer precludes which of the following? None of the above. Application of endoscopic therapy doesn't prevent us or being able to offer any of the above therapies to the patient. And that's why in most of the cases it's always for us to try if we can. Curative endoscopic therapy can be attained in patients with which type of disease? T1a. Now again this question is being referred to EMR and not yes, d. All of the following are considered high risk factors for metastatic disease except? Tumor size greater than two centimeters in length. Tumor sizes nothing to do with whether or not there's risk or metastatic disease. The other four options there are all carry prognostic information with respect whether or not a patient has higher risk or low risk from metastatic disease that we discussed earlier. Number 4, Ways to reduce risk of post EMR esophageal stricturing include. We try to limit resection to less than 50% of the luminal circumference. Thanks very much for watching. I hope you are able to take away what you were supposed to from the lecture theories. And I hope it got you excited about enscopic therapies and enscopic management of esophageal cancer. We've come a long way in the fact that we can now look at a patient and say, you have esophageal cancer, but we can give you information about how deep this goes. We can give you information about what your prognosis is, and there's something other than just getting your esophagus taken out on the table in terms of therapy and that's pretty exciting. Thanks.
