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Clinical Sciences
Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer - initial experience of a western center
Dalton Marques ChavesI, Fauze Maluf FilhoII, Eduardo G.H. de MouraI, Marcos Eduardo Lera dos SantosI, Livia Ronise Garcia ArraisI, Fabio KawagutiII, Paulo SakaiII
I Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
II Cancer Institute of São Paulo - São Paulo/SP, Brazil., Tel.: 55 11 3069.6221,
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">INTRODUCTION</span><p id="para150" class="elsevierStylePara elsevierViewall">Upper gastrointestinal &#40;GI&#41; endoscopy has been valuable for the diagnosis&#44; staging and treatment of early-stage GI neoplasias&#46; Lesions confined to the mucosa throughout the GI tract are susceptible to endoscopic resection&#44; allowing for minimally invasive and curative treatment&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">The resection of neoplastic tissue through endoscopic techniques&#44; known as endoscopic mucosal resection &#40;EMR&#41;&#44; allows for histological analysis of the resected specimen&#44; thereby allowing diagnostic confirmation and determination of the degree of invasion depth into the wall of the organ&#46; This is relevant for determining whether the endoscopic resection was curative&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">Currently&#44; there are several EMR methods that may be divided according to the technique of mucosal capture into&#58; traction &#40;strip-biopsy or lift-and-cut&#41;&#59; suction &#40;cap and elastic band ligation&#41;&#59; and compression &#40;monofilament snare&#41;&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">Endoscopic submucosal resection &#40;ESD&#41; is a new Japanese technique that involves en-bloc resection of the entire lesion irrespective of size&#44; allowing for a detailed analysis of the resected margins and depth of invasion and producing a lower local recurrence when compared to EMR techniques &#40;1&#41;&#46; Most of the relevant series on ESD describe the experience of eastern centers&#44; where it is already incorporated into routine practice&#46; Based on the eastern experience&#44; it is clear that ESD is a complex and time-consuming technique&#44; which are factors that might hinder the diffusion of this new modality of endoscopic treatment&#46;</p><p id="para190" class="elsevierStylePara elsevierViewall">The aim of this study is to report the feasibility of ESD in our institution&#44; specifically addressing the initial results and the technique employed&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">PATIENTS AND METHODS</span><p id="para200" class="elsevierStylePara elsevierViewall">Between March 2007 and January 2009&#44; 20 patients with early stage gastric or esophageal cancer were prospectively included in the present study&#46; They were treated by two senior physicians using the ESD technique&#44; which was performed in the Gastrointestinal Endoscopy Unit of the Clinics Hospital and the Cancer Institute of the S&#227;o Paulo University&#46; The procedures were performed with the consent of the patients after they were informed of the risks and benefits of the method&#46;</p><p id="para210" class="elsevierStylePara elsevierViewall">Before the procedure was developed&#44; all of the diagnoses were done through endoscopic biopsies&#44; and staging was done by echo-endoscopy with a 12 MHz miniprobe&#44; except in cases in which endoscopy was highly suggestive of an early lesion&#46;</p><p id="para220" class="elsevierStylePara elsevierViewall">Using a standard video endoscope &#40;Olympus GIF-Q140 or GIF-Q160&#59; Olympus&#44; Tokyo&#44; Japan&#41; with 2&#37; Lugol&#8217;s solution for the esophagus and 0&#46;4&#37; Indigocarmin for the stomach&#44; the lesions were classified as Japanese endoscopic superficial cancer&#44; and we observed the location and superficial extent of the lesions&#46;</p><p id="para230" class="elsevierStylePara elsevierViewall">The indication and cure criteria adopted for ESD in the stomach were the same as those published by Godota et al&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> &#40;<a class="elsevierStyleCrossRef" href="#t1-cln_65p377">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="t1-cln_65p377"></elsevierMultimedia><p id="para240" class="elsevierStylePara elsevierViewall">The indications and cure criteria for ESD in the esophagus have also been previously described <span class="elsevierStyleBold"><span class="elsevierStyleSup">&#40;2&#44; 3&#44; 4&#41;</span></span> &#40;<a class="elsevierStyleCrossRef" href="#t2-cln_65p377">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="t2-cln_65p377"></elsevierMultimedia><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Technical method of ESD employed</span><p id="para250" class="elsevierStylePara elsevierViewall">The ESD was done using a needle knife with a ceramic ball in its tip&#44; known as an insulation-tipped diathermic knife &#40;IT-knife&#44; Olympus Inc&#46; S&#227;o Paulo&#44; Brazil&#41;&#46;</p><p id="para260" class="elsevierStylePara elsevierViewall">The technique employed had the following basic stages&#58; marking of the periphery of the lesion with a conventional needle knife set at 20 W coagulation mode &#40;ICC200&#44; Erbe&#44; Tubingen&#44; Germany&#41;&#59; injection of 250 ml of saline solution or Manitol &#40;10&#37;&#41; &#43; 1 ml of epinephrine &#40;1&#58;1000&#41; &#43; 2 mL of 0&#46;5&#37; indigo carmine dye into the submucosa&#59; generation of small incisions in the mucosa at the periphery of the lesion at four cardinal points with the conventional needle knife set at 80 W endocut mode with effect 3 &#40;ICC200&#44; Erbe&#44; Tubingen&#44; Germany&#41;&#59; circumferential mucosal cutting with the IT knife gathering the four openings performed with the needle knife&#59; and submucosal dissection of the entire lesion with the IT knife &#40;re 1&#41;&#46;</p><p id="para270" class="elsevierStylePara elsevierViewall">Prophylactic antibiotic IV was administered in all patients&#46;</p><p id="para280" class="elsevierStylePara elsevierViewall">The time of the procedure was recorded in all cases from the point of marking the periphery of the lesion to the complete resection of the lesion&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Post EDS histological analyses</span><p id="para290" class="elsevierStylePara elsevierViewall">The resected specimens were retrieved&#44; stretched and pinned onto a Styrofoam plate&#44; and fixed in 10&#37; formalin&#46; Histological evaluation was performed using Japanese criteria&#44; and the following points were analyzed&#58; degree of differentiation&#44; depth of invasion per the Japanese classification of early-stage cancer&#44; and lateral margin involvement by the lesion&#46;</p><p id="para300" class="elsevierStylePara elsevierViewall">The resection was considered curative if it met the criteria of resection presented in <a class="elsevierStyleCrossRefs" href="#t1-cln_65p377">Tables 1 and 2</a>&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Follow-up</span><p id="para310" class="elsevierStylePara elsevierViewall">Double-dose proton pump inhibitor treatment was given after the procedure and continued for two months&#46;</p><p id="para320" class="elsevierStylePara elsevierViewall">Only patients with small lesions &#40;&#60;1&#46;5 cm&#41; in the gastric antrum were discharged in the first 4 to 6 hr&#46; The others remained in the hospital for 24 hr&#46;</p><p id="para330" class="elsevierStylePara elsevierViewall">Endoscopic control was done at 3&#44; 6&#44; 12 and 18 months after the procedure&#46; In the absence of signs of residual or recurrent lesions after a period of 18 months&#44; annual endoscopic control was indicated&#46;</p></span></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">RESULTS</span><p id="para340" class="elsevierStylePara elsevierViewall">From the 20 patients included in the present study&#44; 22 lesions were resected&#44; including 16 gastric adenocarcinomas and 6 esophageal squamous carcinomas &#40;<a class="elsevierStyleCrossRef" href="#f1-cln_65p377">Figure 1</a>&#41;&#46; The clinicopathological characteristics of the cases are shown in <a class="elsevierStyleCrossRef" href="#t3-cln_65p377">Table 3</a>&#46;</p><elsevierMultimedia ident="f1-cln_65p377"></elsevierMultimedia><elsevierMultimedia ident="t3-cln_65p377"></elsevierMultimedia><p id="para350" class="elsevierStylePara elsevierViewall">From the 15 patients with gastric lesions&#44; we resected 16 lesions&#46; No immediate or late complications&#44; such as hemorrhage&#44; perforation and stenosis&#44; occurred in these cases&#46; The only lesion with Sm2 invasion was referred for surgery&#46; The two patients with Sm1 invasion did not present compromised margins&#59; however&#44; one patient had a focus of vascular invasion by the tumor&#46; Clinical follow-up was opted for in this case&#44; because the patient was diagnosed with sarcoma in the thigh with several pulmonary metastases&#46; In the other patient with Sm1 invasion&#44; surgery was indicated due to the undifferentiated nature of the lesion&#44; and a residual lesion was not found in the surgical specimen&#46;</p><p id="para360" class="elsevierStylePara elsevierViewall">Three lesions were not removed in the monoblock&#58; one located in the cardia measuring 15 mm&#44; one in the posterior region of the antrum measuring 20 mm&#44; and the other in the angular incisure measuring 35 mm in its greatest axis&#46;</p><p id="para370" class="elsevierStylePara elsevierViewall">Three lesions presented with compromised lateral margins&#46; One lesion was complemented 30 days after ESD with EMR using the monofilament technique&#46; The second was in a patient with an undifferentiated carcinoma with affected lateral and deep margins &#40;Sm2&#41;&#59; this patient was referred for surgical treatment after improvement of his clinical condition of common variable immunodeficiency&#44; where a focus of residual carcinoma was confirmed&#46; For the third case with affected lateral margins&#44; an endoscopic control was done 30 days after ESD&#46; Several biopsy specimens were obtained from the resected border and determined to have no residual focus of carcinoma&#46; Control follow-up was performed 90 days after resection&#44; and the biopsies still did not have signs of residual lesion&#46;</p><p id="para380" class="elsevierStylePara elsevierViewall">Excluding the two patients who underwent further surgery&#44; the mean follow-up time was 9&#46;5 months &#40;2&#8211;24 months&#41;&#44; with one patient dying from pneumonia seven months following the resection&#46; One patient developed a new gastric metachronous adenocarcinoma after one year of follow-up&#44; which was also resected using the ESD technique&#46; The lesion was located next to the pylorus&#44; and the resection of this lesion involved almost two-thirds of the circumference of the pyloric canal without progressing to stenosis&#46;</p><p id="para390" class="elsevierStylePara elsevierViewall">From the five patients with esophageal squamous cell carcinoma&#44; six lesions were removed&#46; All patients were in treatment or follow-up of neck and head tumors&#46; Two patients presented with pain and small pneumomediastinum&#59; however&#44; there was no evidence of perforation&#46; Both cases had a good evolution with conservative treatment&#46; Other complications&#44; like bleeding and stenosis&#44; did not happen&#46; All had free lateral and deep margins&#46; In four patients&#44; the mean follow-up time was nine months &#40;5&#8211;20 months&#41; without residual or recurrent tumor&#46; One patient was lost to follow-up&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">DISCUSSION</span><p id="para400" class="elsevierStylePara elsevierViewall">The presence of lymph node metastasis is closely related to the degree of invasion into the esophageal and gastric wall&#46;</p><p id="para410" class="elsevierStylePara elsevierViewall">Esophageal lesions confined to M1 and M2 layers do not present lymph node metastasis&#46; As the lesion becomes deeper&#44; the incidence of metastasis is&#58; M3 &#40;9&#46;1&#37;&#41;&#44; Sm1 &#40;15&#46;4&#37;&#41;&#44; Sm2 &#40;40&#46;0&#37;&#41;&#44; and Sm3 &#40;44&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><p id="para420" class="elsevierStylePara elsevierViewall">According to the incidence of lymph node metastasis and local recurrence&#44; Makuuchi<a class="elsevierStyleCrossRef" href="#bib5">5</a> defined the criteria for the endoscopic mucosal resection &#40;EMR&#41; of early esophageal lesions in 1996&#46; The evolution of endoscopic resection methods has expanded the range of indications for endoscopic resections&#44; but such procedures are formally not indicated in cases with Sm2 and Sm3 invasion detected on endoscopic ultrasound&#46;</p><p id="para430" class="elsevierStylePara elsevierViewall">In the stomach&#44; the incidence of lymph node metastasis for lesions confined to the mucosa and submucosa is generally considered to range from 0&#37; to 3&#37; and 9&#37; to 19&#37;&#44; respectively <a class="elsevierStyleCrossRef" href="#bib6">6</a>&#46;</p><p id="para440" class="elsevierStylePara elsevierViewall">An analysis of 1&#44;312 gastrectomies for gastric cancer<a class="elsevierStyleCrossRef" href="#bib7">7</a> demonstrated a lymph node metastasis rate of 0&#46;64&#37; &#40;3&#47;462&#41; for intestinal cancer confined to the mucosa&#44; irrespective of the size of the lesion&#46; The incidence of metastasis for undifferentiated lesions is rather high&#44; even for lesions smaller in size&#46;</p><p id="para450" class="elsevierStylePara elsevierViewall">In a study conducted at the National Cancer Center Hospital and the Cancer Institute Hospital in Tokyo<a class="elsevierStyleCrossRef" href="#bib8">8</a> on 3&#44;016 intramucosal cancer lesions and 2&#44;249 in the submucosa&#44; the incidence of lymph node metastases was 2&#46;2&#37; for intramucosal cancers and 17&#46;9&#37; for the submucosal cancers&#46; For the well-differentiated intramucosal cancers&#44; none of the 929 lesions without ulceration were associated with nodal metastases regardless of the size of the lesion&#46; Depressed or ulcerated lesions larger than 30 mm and with invasion into the lymphatic system or venules were associated with metastases&#46; The overall risk of LN metastases in undifferentiated lesions was 4&#46;2&#37;&#46; However&#44; none of the 141 intramucosal undifferentiated lesions without ulceration less than 20 mm in size showed lymph node metastases&#46; For submucosal invasive cancer&#44; 145 lesions smaller than 30 mm that were well-differentiated&#44; lacked lymphovascular invasion&#44; and had submucosal penetration &#60; 500 &#956;m &#40;Sm1&#41; were free of lymph node metastasis&#46;</p><p id="para460" class="elsevierStylePara elsevierViewall">The technique of submucosal dissection using the IT-knife was the first technique of endoscopic mucosal dissection used in the National Cancer Center Hospital&#44; Japan&#46;<a class="elsevierStyleCrossRefs" href="#bib9">9&#44;10</a> Other ESD techniques were subsequently developed using different types of accessories&#44; such as the hook-knife&#44; the flex-knife&#44; the triangle-tipped knife&#44; and&#44; more recently&#44; the flush-knife and dual-knife&#46;</p><p id="para470" class="elsevierStylePara elsevierViewall">In contrast to EMR techniques&#44; ESD allows for large en-bloc resections&#44; contributing to better evaluation of resected specimens and consequently lower local recurrence of the neoplasia&#46; In a previous series from our group&#44; endoscopic mucosal resection &#40;EMR&#41; of gastric cancer in more than two fragments &#40;piecemeal resection&#41; was a risk factor for incomplete resection &#40;OR&#61;7&#46;34&#41;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#46; The incidence of local recurrence after EMR procedures ranges from 2&#46;3&#37; to 36&#46;5&#37;&#44; whereas for ESD it ranged from 0&#37; to 2&#37; in initial studies <a class="elsevierStyleCrossRef" href="#bib1">1</a>&#46; For en-bloc resection of gastric neoplasias&#44; success rates for both techniques are similar and over 90&#37; for lesions smaller than 1 cm in diameter&#46; For lesions larger than 1 cm&#44; endoscopic submucosal dissection has a success rate of over 90&#37;&#44; but for mucosectomies&#44; this rate is decreased by half&#46;<a class="elsevierStyleCrossRef" href="#bib12">12</a></p><p id="para480" class="elsevierStylePara elsevierViewall">The ESD procedure duration and incidence of complications are directly related to the experience of the endoscopist with this method&#46;</p><p id="para490" class="elsevierStylePara elsevierViewall">The lesion that presented the most technical difficulty in this study was located in the cardia&#44; where the procedure lasted 2 hours and 30 min&#46; Another difficult lesion was located in the angular incisure&#44; where the procedure lasted 2 hours and 40 min&#44; with a lesion extension of 3&#46;5 cm&#46; The lesions that presented the least technical difficulty were located in the antrum&#44; particularly in the anterior distal region&#44; where the procedure lasted only 20 min&#46;</p><p id="para500" class="elsevierStylePara elsevierViewall">The perforation incidence with different EMR techniques ranged from 0&#37; to 4&#46;0&#37;&#44; whereas with ESD it ranged from 0&#37; to 5&#46;0&#37;&#46; When comparing these methods&#44; Watanabe and colleagues<a class="elsevierStyleCrossRef" href="#bib12">12</a> did not identify a statistical difference in the incidence of perforation&#44; which was 3&#46;2&#37; for EMR and 4&#46;2&#37; for ESD&#46;<a class="elsevierStyleCrossRef" href="#bib12">12</a> However&#44; Oka and colleagues<span class="elsevierStyleSup">23</span> analyzed only non-ulcerative lesions and found a 0&#46;5&#37; incidence for EMR and a 9&#46;7&#37; incidence for EDS with statistical difference&#46; Oda et al&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a>&#44; in a multicenter retrospective study of early gastric cancer&#44; observed the incidence of perforation with ESD &#40;3&#46;6&#37;&#59; 11&#47;303&#41; to be significantly higher than that with EMR &#40;1&#46;2&#37;&#59; 5&#47;411&#41;&#46;</p><p id="para510" class="elsevierStylePara elsevierViewall">Bleeding is the most frequent complication for techniques of endoscopic resection&#46; Its incidence for EMR was found to reach 8&#37;&#44; whereas for ESD it reached 7&#37;&#46; Oka and colleagues<a class="elsevierStyleCrossRef" href="#bib14">14</a> found that the incidence of bleeding during and after EMR was 7&#46;6&#37; and 3&#46;9&#37;&#44; respectively&#44; for non-ulcerative lesions&#44; whereas this incidence during and after ESD was 22&#46;6&#37; and 6&#46;2&#37;&#44; respectively&#46; In a study by Oda<a class="elsevierStyleCrossRef" href="#bib13">13</a> et al&#46;&#44; only one patient submitted to EMR required blood transfusion&#59; no patients in the ESD group required transfusion&#46;</p><p id="para520" class="elsevierStylePara elsevierViewall">Both perforation and bleeding are endoscopically treated with great success&#46;</p><p id="para530" class="elsevierStylePara elsevierViewall">In the present study&#44; there were no cases of perforation or other significant complications&#46;</p><p id="para540" class="elsevierStylePara elsevierViewall">Given the present results and the data in the literature&#44; we conclude that the ESD technique is feasible in our environment&#46;</p></span></span>"
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          "identificador" => "xpalclavsec1582843"
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        1 => array:2 [
          "identificador" => "cesec10"
          "titulo" => "INTRODUCTION"
        ]
        2 => array:3 [
          "identificador" => "cesec20"
          "titulo" => "PATIENTS AND METHODS"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "cesec30"
              "titulo" => "Technical method of ESD employed"
            ]
            1 => array:2 [
              "identificador" => "cesec40"
              "titulo" => "Post EDS histological analyses"
            ]
            2 => array:2 [
              "identificador" => "cesec50"
              "titulo" => "Follow-up"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "cesec60"
          "titulo" => "RESULTS"
        ]
        4 => array:2 [
          "identificador" => "cesec70"
          "titulo" => "DISCUSSION"
        ]
        5 => array:1 [
          "titulo" => "REFERENCES"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2009-11-09"
    "fechaAceptado" => "2010-01-19"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS&#58;"
          "identificador" => "xpalclavsec1582843"
          "palabras" => array:6 [
            0 => "Endoscopic mucosal"
            1 => "resection"
            2 => "endoscopic submucosal dissection"
            3 => "early gastric cancer"
            4 => "early esophageal cancer"
            5 => "endoscopy"
          ]
        ]
      ]
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    "resumen" => array:1 [
      "en" => array:2 [
        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">BACKGROUND</span><p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size&#44; with lower local recurrence when compared to endoscopic mucosal resection&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">OBJECTIVE</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">To evaluate the feasibility&#44; early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the S&#227;o Paulo University&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">MATERIALS AND METHODS</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer&#46; The patients were evaluated prospectively as to the executability of the technique&#44; the short-term results of the procedure and complications&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">RESULTS</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected&#46; In the stomach&#44; the mean diameter of the lesions was 16&#46;2 mm &#40;0&#46;6&#8211;3&#46;5 mm&#41;&#46; Eight lesions were type IIa &#43; IIc&#44; four were type IIa and four IIc&#44; with thirteen being well differentiated and three undifferentiated&#46; Regarding the degree of invasion&#44; five were M2&#44; seven were M3&#44; two were Sm1 and one was Sm2&#46; The mean duration of the procedures was 85 min &#40;20&#8211;160 min&#41;&#46; In the esophagus&#44; all of the lesions were type IIb&#44; with a mean diameter of 17&#46;8 mm &#40;6&#8211;30 mm&#41;&#46; Regarding the degree of invasion&#44; three were M1&#44; one was M2&#44; one was M3 and one was Sm1&#46; All had free lateral and deep margins&#46; The mean time of the procedure was 78 min &#40;20&#8211;150 min&#41;</p></span> <span id="ceabs50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">CONCLUSION</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">The endoscopic submucosal dissection technique was feasible in our service with a high success rate&#46;</p></span>"
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            "titulo" => "BACKGROUND"
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            "titulo" => "OBJECTIVE"
          ]
          2 => array:2 [
            "identificador" => "ceabs30"
            "titulo" => "MATERIALS AND METHODS"
          ]
          3 => array:2 [
            "identificador" => "ceabs40"
            "titulo" => "RESULTS"
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          4 => array:2 [
            "identificador" => "ceabs50"
            "titulo" => "CONCLUSION"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Endoscopic submucosal dissection of a gastric adenocarcinoma &#40;IIa&#43;IIc&#41;&#46; A- Marking of the lesion&#46; B- Circumferential cutting around the entire lesion&#46; C- Submucosal dissection of the lesion with the IT-knife&#46; D- Complete resection of the lesion&#46; E- ESD specimen &#40;one piece&#41;&#46;</p>"
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      1 => array:7 [
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        "etiqueta" => "Table 1"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col"><span class="elsevierStyleBold">INTRAMUCOSAL CANCER</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col"><span class="elsevierStyleBold">SUBMUCOSAL CANCER</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Differentiated adenocarcinoma</span><ul class="elsevierStyleList" id="celist10"><li class="elsevierStyleListItem" id="celistitem10"><p id="para10" class="elsevierStylePara elsevierViewall">- No lymphatic-vascular invasion</p></li><li class="elsevierStyleListItem" id="celistitem20"><p id="para20" class="elsevierStylePara elsevierViewall">- Irrespective of tumor size without ulcer findings</p></li><li class="elsevierStyleListItem" id="celistitem30"><p id="para30" class="elsevierStylePara elsevierViewall">- Tumor less than 3 cm in size with ulcer findings</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><ul class="elsevierStyleList" id="celist20"><li class="elsevierStyleListItem" id="celistitem40"><p id="para40" class="elsevierStylePara elsevierViewall">- Superficial submucosal invasion&#44; &#60; 500 &#956;m &#40;Sm1&#41;</p></li><li class="elsevierStyleListItem" id="celistitem50"><p id="para50" class="elsevierStylePara elsevierViewall">- Differentiated adenocarcinoma</p></li><li class="elsevierStyleListItem" id="celistitem60"><p id="para60" class="elsevierStylePara elsevierViewall">- No lymphatic-vascular invasion</p></li><li class="elsevierStyleListItem" id="celistitem70"><p id="para70" class="elsevierStylePara elsevierViewall">- Tumor less than 3 cm in size</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Undifferentiated adenocarcinoma</span><ul class="elsevierStyleList" id="celist30"><li class="elsevierStyleListItem" id="celistitem80"><p id="para80" class="elsevierStylePara elsevierViewall">- No lymphatic-vascular invasion</p></li><li class="elsevierStyleListItem" id="celistitem90"><p id="para90" class="elsevierStylePara elsevierViewall">- No ulcer findings</p></li><li class="elsevierStyleListItem" id="celistitem100"><p id="para100" class="elsevierStylePara elsevierViewall">- Tumor less than 2 cm in size</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><ul class="elsevierStyleList" id="celist40"><li class="elsevierStyleListItem" id="celistitem110"><p id="para110" class="elsevierStylePara elsevierViewall">- Endoscopic signs of early lesions or echo endoscopic examination confirming tumor limited to the mucosa or up to the superficial submucosa &#40;Sm1&#41;&#46;</p></li><li class="elsevierStyleListItem" id="celistitem120"><p id="para120" class="elsevierStylePara elsevierViewall">- Histological confirmation of squamous cell carcinoma or high grade intraepithelial neoplasia restricted to the mucosa &#40;M1 and M2&#41;&#46;</p></li><li class="elsevierStyleListItem" id="celistitem130"><p id="para130" class="elsevierStylePara elsevierViewall">- Lesions with M3 or Sm1 invasion without lymphatic and vascular involvement&#44; no larger superficial size &#40;&#60; 2&#46;5 mm&#41;&#46;</p></li><li class="elsevierStyleListItem" id="celistitem140"><p id="para140" class="elsevierStylePara elsevierViewall">- No signs of lymph node metastases&#46;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Indication criteria adopted for esophageal cancer endoscopic submucosal resection</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col">GASTRIC LESIONS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">ESOPHAGEAL LESIONS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Patients&#47;lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">15&#47;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean age &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#46;1 &#40;32&#8211;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;8 &#40;48&#8211;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">4 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LOCATION&#44; N</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antrum&#44; body&#44; cardia&#44; angular incisure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44; 4&#44; 3&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Middle&#44; distal part&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44; 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lesion size&#44; median &#40;range&#41;&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;2 &#40;0&#46;6 &#8211; 3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;8 &#40;6&#8211;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MACROSCOPIC TYPE&#44; N</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa &#43; IIc&#44; IIa&#44; IIc&#44; IIb&#44; IIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44; 4&#44; 4&#44; 0&#44; 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44; 0&#44; 0&#44; 5&#44; 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Procedure times&#44; median &#40;range&#41;&#44; min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 &#40;20&#8211;150&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78 &#40;20&#8211;150&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En-block resection&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;81&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;83&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DEPTH OF INVASION</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M1&#44; M2&#44; M3&#44; Sm1&#44; Sm2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44; 5&#44; 8&#44; 2&#44; 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44; 1&#44; 1&#44; 1&#44; 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lateral margins compromised&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;18&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HISTOLOGIC TYPE&#44; N &#40;&#37;&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Well-differentiated adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;81&#46;2&#37;&#41;&#44;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Undifferentiated adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;18&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Squamous cell carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">COMPLICATIONS&#44; N</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immediate bleeding&#44; later bleeding&#44; stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44; 0&#44; 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44; 0&#44; 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perforations&#44; pneumomediastinum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44; 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44; 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Clinicopathological characteristics&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
          "bibliografiaReferencia" => array:14 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endoscopic resections of early gastric cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              T Gotoda \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10120-007-0444-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastric Cancer"
                        "fecha" => "2007"
                        "volumen" => "11"
                        "paginaInicial" => "10"
                        "paginaFinal" => "11"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18373172"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              M Ciocirlan \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              MG Lapalus \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              V Hervieu \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              J C Souquet \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              B Napol&#233;on \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              JY Scoazec \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-2006-945182"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endoscopy"
                        "fecha" => "2007"
                        "volumen" => "39"
                        "paginaInicial" => "24"
                        "paginaFinal" => "29"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17252456"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Expansion of the indications for endoscopic mucosal resection in patients with superficial esophageal carcinoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              K Higuchi \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              S Tanabe \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              W Koizumi \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              T Sasaki \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              K Nakatani \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              K Saigenji \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-2006-945148"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endoscopy"
                        "fecha" => "2007"
                        "volumen" => "39"
                        "paginaInicial" => "36"
                        "paginaFinal" => "40"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17252458"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              R Ishihara \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              H Iishi \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              Y Takeuchi \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              M Kato \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              S Yamamoto \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              E Masuda \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Gastroint Endosc"
                        "fecha" => "2008"
                        "volumen" => "67"
                        "paginaInicial" => "799"
                        "paginaFinal" => "804"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endoscopic mucosal resection for early esophageal cancer&#58; indications and techniques"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              H Makuuchi \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Digestive Endoscopy"
                        "fecha" => "1996"
                        "volumen" => "8"
                        "paginaInicial" => "175"
                        "paginaFinal" => "179"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcome of endoscopic mucosal resection for early gastric cancer&#58; review of the Japanese literature"
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es en pt

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