Frontoethmoid Osteoma Operated by Combined Approach: A Case Report

Osteoma is the most common benign neoplasm of the nose and paranasal sinuses. Despite their size, (osteomas can often reach several centimeters) they most often remain asymptomatic. Generally conservative treatment is recommended for asymptomatic osteomas, while symptomatic osteomas should be resected. As the frontal sinus is commonly affected, most surgical approaches mainly concentrate on resection of osteoma by external route endoscopic instruments offer an alternative approach to sinus surgery, enabling closer and more direct visualization of the anatomy, avoiding damage to surrounding structures as well as avoiding an external scar. In this article we describe a combined approach i.e. osteoplastic flap technique combined with endosocopic resection of a frontoethmoid osteoma. With proficient use of this method, complete removal of such tumours can be achieved with minimal morbidity.

Early Esophageal Cancer: A Gastroenterologist's Disease

Traditionally, early esophageal cancer (i.e., cancer limited to the mucosa or superficial submucosa) was managed surgically; the gastroenterologist's role was primarily to diagnose the tumor. Over the last decade, advances in endoscopic imaging, ablation, and resection techniques have resulted in a paradigm shift-diagnosis, staging, treatment, and surveillance are within the endoscopist's domain. Yet, there are few reviews that provide a focused, evidence-based approach to early esophageal cancer, and highlight areas of controversy for practicing gastroenterologists. In this manuscript, we will discuss the following: (1) utility of novel endoscopic technologies to identify high-grade dysplasia and early esophageal cancer, (2) role of endoscopic resection and imaging to stage early esophageal cancer, (3) endoscopic therapies for early esophageal cancer, and (4) indications for surgical and multidisciplinary management.

Bleeding after Endoscopic Resection in Patients with End-Stage Renal Disease on Dialysis: A Multicenter Propensity Score-Matched Analysis

Background/Aims

Frequent bleeding after endoscopic resection (ER) has been reported in patients with end-stage renal disease (ESRD). We aimed to evaluate the association and clinical significance of bleeding with ER in ESRD patients on dialysis.

Methods

Between February 2008 and December 2018, 7,571 patients, including 47 ESRD patients on dialysis who underwent ER for gastric neoplasia, were enrolled. A total of 47 ESRD patients on dialysis were propensity score-matched 1:10 to 470 non-ESRD patients, to adjust for between-group differences in variables such as age, sex, comorbidities, anticoagulation use, tumor characteristics, and ER method. Matching was performed using an optimal matching algorithm. For the matched data, clustered comparisons were performed using the generalized estimating equation method. Medical records were retrospectively reviewed. Frequency and outcomes of post-ER bleeding were evaluated.

Results

Bleeding was more frequent in the ESRD with dialysis group than in the non-ESRD group. ESRD with dialysis conferred a significant risk of post-ER bleeding (odds ratio, 6.1; 95% confidence interval, 2.7–13.6; p<0.0001). All post-ER bleeding events were controlled using endoscopic hemostasis except in 1 non-ESRD case that needed surgery.

Conclusions

ESRD with dialysis confers a bleeding risk after ER. However, all bleeding events could be managed endoscopically without sequelae. Concern about bleeding should not stop endoscopists from performing ER in ESRD patients on dialysis.

Snare-assisted endoscopic resection of gastric subepithelial tumors originating from the muscularis propria layer: a multicenter study

BACKGROUND AND AIM

Although successful endoscopic resection of gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer has been frequently reported, it requires a relatively complicated technique and has a high perforation rate. In this retrospective study, we evaluated the efficacy and safety of the snare-assisted endoscopic resection (SAER) method which is performed using a snare and insulated-tip (IT) knife via a single-channel endoscope to reduce the perforation rate.

METHODS

In this study, fifty-six patients with gastric SETs originating from the MP layer treated by the SAER method at three institutions between July 2017 and December 2017 were reviewed. The procedure involved multiple steps as shown in Fig. 2. Data were obtained on demographics, SET features, histopathological diagnoses, procedure time, en bloc resection rate, R0 resection (negative margins) status, and adverse events.

RESULTS

Endoscopic resection was successfully performed in all patients. The median overall procedure time was 43.5 min (range 26-106 min). The mean size of resected specimens was 19.73 mm (range 10-33 mm). The overall rate of en bloc resection was 96.4% (54/56). In addition, the perforation rate was 7.1% (4/56), and defects in the stomach wall were very small and easily closed using metallic clips. No postprocedural bleeding occurred in any case.

CONCLUSIONS

The SAER method is an effective, safe, less costly technique for the removal of some gastric SETs originating from the MP layer with an appropriate size.

Long-term outcomes of endoscopically resected laterally spreading tumors with a positive histological lateral margin

BACKGROUND

With advances in diagnostic endoscopy, the incidence of superficial colorectal tumors, including laterally spreading tumors (LSTs), has increased. However, little is known about the long-term results of LSTs with positive lateral margin after endoscopic treatment. This study aimed to evaluate the long-term clinical outcomes and risk factors for local recurrence of LSTs with positive lateral margin after initial endoscopic resection.

METHODS

We performed a retrospective analysis of the medical records of 324 patients who had 363 LSTs with positive lateral margin after endoscopic resection at a tertiary academic medical center. The medical records from 2011 to 2015 were analyzed. Local recurrence was confirmed through endoscopic finding and subsequent biopsy analysis. We assessed the local recurrence rate and performed multivariate analyses to identify the factors associated with local recurrence.

RESULTS

Follow-up colonoscopy was performed in 176 of 363 LSTs. The local recurrence rate was 6.3% (11/176), with a median (interquartile range [IQR]) follow-up period of 19.8 (12.4-46.5) months. In multivariate analysis, local recurrence was associated with piecemeal resection (odds ratio [OR] 6.62, 95% confidence interval [CI] 1.28-34.33; p = 0.024) and inversely associated with thermal ablation (OR 0.033, 95% CI 0.00-0.45; p = 0.011). At surveillance colonoscopy, histology of the recurrent tumor was adenoma in 10 (90.9%) of 11; these were treated endoscopically.

CONCLUSIONS

In this retrospective study, we found that endoscopically resected LSTs with positive lateral margin have a low recurrence rate. Piecemeal resection was associated with higher local recurrence, and thermal ablation was inversely associated with local recurrence. Endoscopic resection with positive lateral margin combined with thermal ablation leads to a low recurrence rate.

Multi-band mucosectomy for neoplasia in patients with Barrett's esophagus: in vivo comparison between two different devices

BACKGROUND

Multi-band mucosectomy (MBM) is effective and safe for Barrett's neoplasia. No studies have yet compared the efficacy and safety of the MBM devices commercially available: Duette™ (CookMedical) and Captivator™ (BostonScientific). Our aim is to compare the two devices.

METHODS

This is a dual-center retrospective case-control study (Rozzano, Portsmouth) comparing efficacy, safety, and histology of resected specimens between Duette™ (DUE) and Captivator™ (CAPT). Efficacy was assessed by R0 and local recurrence (LR) rate. Bleedings, perforations, and strictures were recorded as safety outcomes. Moreover, the specimens were re-examined by two pathologists, blinded about the study group, to assess the maximum thickness of both the whole specimens and the resected submucosal layer.

RESULTS

Seventy-six patients (38 per group) were included. The two groups did not differ in terms of baseline characteristics. R0 resection was achieved in 96.7% versus 96.3% (p = ns) and LR were recorded in 4/38 (10.5%) versus 3/38 (7.9%) in DUE and CAPT group, respectively (p = ns). Considering Duette™ versus Captivator™, 2 versus 3 patients developed a symptomatic stricture. Only one post-procedural bleeding occurred (Captivator™). Maximum medium thicknesses of specimens and of resected submucosa did not differ between the groups.

CONCLUSIONS

MBM is safe and effective for resecting visible lesions using either of the two available devices.

Predicting lymph node metastases with endoscopic resection in cT2N0M0 oesophageal cancer: A systematic review and meta-analysis

Background

Despite modern imaging modalities, staging of clinically staged T2N0M0 (cT2N0M0) oesophageal cancer is suboptimal, often leading to overtreatment. Endoscopic resection – the first-line therapy for early localised tumours – could be used to improve staging and to attain predictors of nodal upstaging enabling more stage-guided treatment decisions.

Objective

A systematic literature review and a meta-analysis were conducted to assess the prevalence and the pathological risk factors of lymph node metastases in cT2N0M0 oesophageal cancer.

Methods

Databases of PUBMED, EMBASE and Cochrane were searched for literature. The primary outcome was lymph node metastases determined after primary surgical resection.

Results

Nine studies with a total of 1650 cT2N0M0 patients were included. The prevalence of lymph node metastases was 43% (95% confidence interval: 35–50%) with heterogeneity being high across studies (I² = 0.86, p < 0.001). Factors potentially attainable by endoscopic resection and having a significant association with lymph node metastases were invasion depth, differentiation grade, tumour size, depth of invasion in the muscularis propria and lymphovascular invasion.

Conclusions

Clinical lymph node staging is inaccurate in almost half of cT2N0M0 oesophageal cancer. Endoscopic resection is a promising diagnostic modality that might even be a valid alternative to surgery in selected patients without high-risk features, but further evidence is warranted.

Endoscopic full-thickness resection of gastric gastrointestinal stromal tumor: a Japanese case series

Background:

Gastrointestinal stromal tumors (GISTs) are potentially malignant and are indicated for resection. The standard treatment for resectable GISTs is surgery, although endoscopic resection has been reported outside Japan. This study retrospectively analyzed the results of endoscopic resection of GISTs in Japan.

Method:

We identified patients with GISTs treated only by endoscopic resection in our institute between January 2016 and December 2018, and analyzed their clinical and pathological characteristics.

Results:

During the study period, 8 GISTs were resected only by endoscopy: 7 were located in the upper third of the stomach and 1 in the middle. All were intraluminal growth type. Median (range) tumor diameter was 20 (10-35) mm. All tumors were resected en bloc with a median (range) operation time of 67.5 (50-166) min. Complete perforation occurred in 5 cases, but the serosa remained in 2 and the outer layer of the muscularis propria remained in 1. The defect was endoscopically closed with clip-and-endoloop purse-string suturing (n=3), simple endoclipping (n=2), or over-the-scope clipping (n=2), and 1 did not require closure because the outer longitudinal muscle was preserved. Oral feeding was commenced on postoperative day (POD) 3 (median; range 2-4), and the patient was discharged on POD 6 (median; range 4-11). No serious adverse event developed after the procedures.

Conclusion:

Endoscopic resection for selected cases of small intraluminal GISTs is feasible, making it a viable alternative treatment option to laparoscopic surgery.

Lymphovascular invasion as a prognostic value in small rectal neuroendocrine tumor treated by local excision: A systematic review and meta-analysis

Because rectal neuroendocrine tumors (NETs) are usually small-sized despite of malignant potential, endoscopic resection techniques are recommended. It is unclear whether the lymphovascular invasion (LVI) in the endoscopic resected specimens of small rectal NETs should be indicated for completion surgery. We performed a systematic review and meta-analysis for the incidence of LVI in small rectal NETs (≤20 mm) treated by endoscopic resection and its prognostic impacts. We searched the relevant literature published before January 2019. A total of 21 publications including 1816 patients were enrolled. Overall prevalence of LVI in small rectal NETs was 21.8%. Immunohistochemical method significantly increased the detection rate of LVI up to 35.8% compared than H&E staining only (13.2%). Tumor size more than 5 mm was a risk factor for LVI in small rectal NET, whereas tumor grade did not influence the risk. The LVI in the endoscopic resected specimens was a risk factor for subsequent lymph node metastasis. Separately analyzed in detail, the vascular invasion had a stronger impact on lymph node metastasis than the lymphatic invasion. The prognosis of endoscopically treated rectal NET with LVI was excellent with only 0.3% of recurrence rate during the 5-year follow-up period. LVI is highly prevalent and a risk factor for lymph node metastasis in the small rectal NETs. Endoscopically treated small rectal NETs had excellent short-term prognoses despite of LVI. Immediate completion radical surgery is not absolutely necessary for the LVI-positive small rectal NETs. However, long-term follow-up is recommended for any delayed recurrence.

A Case of a Bleeding Duodenal Lipoma Successfully Controlled by Endoscopic Resection

This is a case report of successful endoscopic resection (ER) of a bleeding duodenal lipoma. An 85-year-old woman who was diagnosed with asymptomatic subepithelial tumor of the duodenum 3 years ago visited the emergency room with hematemesis and was admitted to our hospital. Emergent esophagogastroduodenoscopy revealed bleeding from an ulcer on the superior aspect of a subepithelial tumor measuring about 20 mm in diameter, at the superior duodenal angle. The ulcer was in the active stage (A1), with a visible vessel. The bleeding was controlled by ER of the tumor using a snare. The final pathological diagnosis was duodenal lipoma with mucosal ulceration. The patient showed no signs of bleeding for 10 days after the procedure; subsequently, she was discharged and followed up for regular checkups.

Comparison of Safety and Outcomes between Endoscopic and Surgical Resections of Small (≤ 5 cm) Primary Gastric Gastrointestinal Stromal Tumors

BACKGROUND AND AIMS

Endoscopic resection is increasingly performed for gastric gastrointestinal stromal tumors (GIST). However, the safety and outcomes remain elusive. We aimed in this retrospective study to compare operative complications and prognosis between endoscopically and surgically resected small (≤ 5 cm) GIST tumor groups.

METHODS

In this single-center retrospective study, we compared demographics, clinical outcomes, and the R0 resection rate between the endoscopy (n =268) and surgery (n =141) groups. Only GIST tumors in size of ≤ 5.0 cm were recruited for this comparison study.

RESULTS

Overall, the mean age of patients was 59.0 years (range: 31.0-83.0). The male-female ratio was 0.68. The most common site of GIST was, in the descending order, the gastric fundus (55%), corpus (27.6%), cardia (10.8%), and antrum (6.6%). Compared with the surgery group, GIST tumors in the endoscopy group were significantly smaller (1.69±0.9 cm, vs. 3.20±1.2 cm in the surgery group; P <0.001) in size; postoperative hospital stay was significantly shorter (4.66±1.5 days, vs. 8.11±5.0; P <0.001); post-resection time to first liquid diet was significantly shorter (1.94±1.1 days, vs. 4.63±2.6; P < 0.001); the incidence of operative and post-operative complications was significantly fewer (p < 0.05), and hospital costs were significantly lower (20115.4±5113.5¥, vs. 43378.4±16795.7¥; P < 0.001). The R0 resection rate was significantly lower in the endoscopy (93.3%) than in the surgery (99.3%) groups (P< 0.01). In the endoscopy group, 176 (65.7%) and 69 (25.7%) patients were found to be at very low and low risk of aggressiveness, respectively, in comparison to 27(19.2%) and 86 (61.0%) patients in the surgery group, respectively (P <0.001). Among 409 cases, 50 (12.2%) were found to be at intermediate or high risk of aggressiveness, 20 of which were treated with adjuvant imatinib therapy and but only 8/20 taking imatinib for 1 to 3 months because of side effects and high costs. No local or distant tumor recurrence was observed over an average of 33.5-month follow-ups. Two patients died of other disease in the surgery group.

CONCLUSIONS

Endoscopic resection of selected small gastric GISTs (≤ 5cm) was feasible, safe, and associated with better intraoperative results and an equal postoperative course, compared to surgical resection.

Colonic Intramucosal Cancer in the Interposed Colon Treated with Endoscopic Mucosal Resection: A Case Report and Review of Literature

Colon interposition is a surgical procedure used for maintenance of luminal conduit after esophagectomy. Although epithelial neoplasia, such as adenoma and adenocarcinoma, may develop in the interposed colon, there are only few case reports on the condition. Due to the rarity of this condition, there is no definite consensus on recommending screening endoscopy for the early detection of neoplasia in the interposed colons. Here, we report a case of intramucosal adenocarcinoma in an interposed colon. Initial endoscopic resection for this tumor failed to accomplish complete resection. A subsequent endoscopic resection was performed 1 month later and complete resection was achieved. Based on our experience and recommendation on screening endoscopy for gastric cancer in Korea, we suggest that regular screening esophagogastroduodenoscopies should be performed following esophagectomy to detect early neoplasia in the stomach and interposed colon and avoid adverse results induced by delayed detection.

Endoscopic full thickness resection for early colon cancer in Lynch syndrome

Subtotal colectomy is usually the therapy of choice in Lynch syndrome patients diagnosed with colon cancer. In patients who develop cancer after the age of 50-60 years, segmental colectomy is considered a good alternative. Although the endoscopic treatment of early colorectal cancer in non-Lynch patients has increased in the last decades, almost all patients with a Lynch syndrome-associated colorectal malignancy undergo surgery, even if the tumour is diagnosed in a (very) early stage. One of the endoscopic treatment options for early colorectal cancer is an endoscopic full thickness resection (eFTR). This treatment modality allows optimal pathological examination of the resection specimen, as a transmural resection is performed with optimal T-staging of the tumour. We report a case of a 62 year old man, diagnosed with MSH2-Lynch syndrome, who underwent successful eFTR treatment of an early (pT1) colon cancer located in the ascending colon, with no signs of recurrence 12 months after treatment. We discuss the pros and cons of endoscopic resection of early colorectal carcinoma in Lynch syndrome patients.

Outcomes of endoscopic resection of large colorectal lesions subjected to prior failed resection or substantial manipulation

PURPOSE

Injudicious attempts at resection and extensive sampling of large colorectal adenomas prior to referral for endoscopic resection (ER) are common. This has deleterious effects, but little is known about the outcomes following ER. We retrospectively analysed the outcomes of ER of large adenomas previously subjected to substantial manipulation.

METHOD

ER of large (≥ 2 cm) colorectal adenomas were grouped according to level of manipulation: prior attempted resection, heavy manipulation (≥ six biopsies or tattoo under lesion) or minimal manipulation (< six biopsies). Outcomes were compared between groups. Independent predictors of outcomes were identified using multiple logistic regression.

RESULTS

Five hundred forty-two lesions (mean size 53.7 mm) were included. Two hundred sixty-five (49%) had been subjected to prior attempted resection or heavy manipulation, 151 (28%) to minimal manipulation, and 126 (23%) were not previously manipulated. ESD techniques were used more frequently than EMR after substantial manipulation. There were no differences in initial success of ER (99%, 98%, 98%, p = 0.71). Prior attempted resection was independently associated with recurrence (OR 2.2, 95% CI 1.1-4.5, p = 0.03) and negatively associated with en bloc resection (OR 0.29, 95% CI 0.1-0.7, p = 0.004). Regardless of level of prior manipulation, there were no differences in sustained endoscopic cure with > 95% of patients overall free from recurrence and avoiding surgery at last follow-up.

CONCLUSION

There is a substantial burden of injudicious lesion manipulation before referral, which makes recurrence more likely and en bloc resection less likely. However, with appropriate expertise, sustained successful endoscopic treatment is achievable for the vast majority of patients treated in a specialist unit.

Endoscopic resection for subepithelial lesions-pure endoscopic full-thickness resection and submucosal tunneling endoscopic resection

Endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) are the frontier of therapeutic endoscopic. These two methods rely on the skillset and equipment of endoscopic submucosal dissection (ESD) while going beyond the boundaries of the gastrointestinal lumen. They are both representatives of natural orifice transluminal endoscopic surgery, with STER being a direct off-shoot of peroral endoscopic myotomy (POEM). Both techniques are designed for the removal of gastrointestinal tumors originating from the muscularis propria but tend to be used in different organs and come with respective challenges. In this review we will go over the history, indication, technique and literature of these two techniques.

Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis

BACKGROUND

The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes.

AIM

To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm.

METHODS

We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I² were used to test for heterogeneity. Pooling was conducted using a random-effects model.

RESULTS

Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies (I² = 0%, P = 0.67).

CONLUSION

Prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

BACKGROUNDS/AIM

We aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality.

METHODS

We reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation.

RESULTS

Herein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC.

CONCLUSIONS

Endoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

Clinical evaluation of endoscopic resection for treatment of large gastric stromal tumors

BACKGROUND

Gastric stromal tumor is a digestive tract mesenchymal tumor with malignant potential, and endoscopic techniques have been widely used in the treatment of gastric stromal tumors, but there is still controversy over their use for large gastric stromal tumors (≥ 3 cm).

AIM

To evaluate the clinical long-term efficacy and safety of endoscopic resection for large (≥ 3 cm) gastric stromal tumors.

METHODS

All patients who underwent endoscopic resection or surgery at our hospital from 2012 to 2017 for pathologically confirmed gastric stromal tumor with a maximum diameter of ≥ 3 cm were collected. The clinical data, histopathologic characteristics of the tumors, and long-term outcomes were recorded.

RESULTS

A total of 261 patients were included, including 37 patients in the endoscopy group and 224 patients in the surgical group. In the endoscopy group, the maximum tumor diameter was 3-8 cm; the male: Female ratio was 21/16; 34 cases had low-risk tumors, 3 had intermediate-risk, and 0 had high-risk; the mean follow-up time was 30.29 ± 19.67 mo, no patient was lost to follow-up, and no patient received chemotherapy after operation; two patients with recurrence had low-risk stromal tumors, and neither had complete resection under endoscopy. In the surgical group, the maximum tumor diameter was 3-22 cm; the male: Female ratio was 121/103; 103 cases had low-risk tumors, 75 had intermediate-risk, and 46 had high-risk; the average follow-up time was 38.83 ± 21.50 mo, 53 patients were lost to follow-up, and 8 patients had recurrence after operation (6 cases had high-risk tumors, 1 had intermediate-risk, and 1 had low-risk). The average tumor volume of the endoscopy group was 26.67 ± 26.22 cm³ (3.75-120), all of which were less than 125 cm³. The average volume of the surgical group was 273.03 ± 609.74 cm³ (7-4114). Among all patients with a tumor volume < 125 cm³, 7 with high-risk stromal tumors in the surgical group (37.625 cm³ to 115.2 cm³) accounted for 3.8% (7/183); of those with a tumor volume < 125 cm³, high-risk patients accounted for 50% (39/78). We found that 57.1% (12/22) of patients with high-risk stromal tumors also had endoscopic surface ulcer bleeding and tumor liquefaction on ultrasound or abdominal computed tomography; the ratio of tumors positive for both in high-risk stromal tumors with a volume < 125 cm³ was 60% (3/5).

CONCLUSION

Endoscopic treatment is safe for 95.5% of patients with gastric stromal tumors with a tumor diameter ≥ 3 cm and a volume of < 125 cm³ without endoscopic surface ulcer bleeding or CT liquefaction.

Efficacy and safety of endoscopic resection for gastric tube cancer after surgical resection of esophageal squamous cell carcinoma

BACKGROUND

Gastric tube cancers (GTCs) are found frequently, even as the surgical outcomes of esophageal cancer improve. Diagnosing and treating early gastric tube cancer endoscopically has therefore become very important.

AIMS

This study aimed to evaluate the clinical characteristics and outcomes of endoscopic resection for GTC.

METHODS

We analyzed 29 patients (33 lesions) with metachronous GTC who underwent endoscopic resection from April 2005 to August 2016 and evaluated their clinical characteristics and the short-term outcomes of endoscopic resection.

RESULTS

All of the cases were identified by periodic examinations. The lesions were found a median of 6.5 years after surgery (range 9 months-19 years), with six lesions found more than 10 years later. Among the total of 33 lesions, 28 resulted in curative resections (85%), and five were non-curative resections because of lymphovascular invasion, submucosal deep invasion, histological type, and size. None had received additional treatment or had a local recurrence thus far. Regarding the complications, delayed perforation occurred in a case (3%) and precordial skin burn occurred in four cases (12%).

CONCLUSION

The safety and efficacy of endoscopic resection for gastric tube cancer were evaluated. Additionally, it is important to continue annual endoscopy even 5 years or more after esophageal surgery.

The Predictive Role of Intraoperative Visual Evoked Potentials in Visual Improvement After Endoscopic Pituitary Tumor Resection in Large and Complex Tumors: Description and Validation of a Method

BACKGROUND

With the advent of extensive endoscopic approaches for pituitary tumors, there has also been an increase in surgery for larger and more complex tumors. Intraoperative manipulation during endoscopic resection of sellar tumors poses potential risk in postoperative visual function in this tumor population. This study proposes a method of accurate intraoperative monitoring of visual evoked potentials (VEPs) and its role in predicting visual function outcomes.

METHODS

Intraoperative VEPs were monitored for 42 resections from a single surgical team, with average tumor size of 2.84 cm. Changes in VEP amplitude and latency in excess of 50% were considered significant. Preoperative and postoperative visual information was obtained from ophthalmology and hospital records, along with patient demographics, comorbidities, and tumor characteristics.

RESULTS

Patients were stratified as experiencing deteriorations in VEPs that did not restore to baseline (n = 4), deteriorations in VEPs that did restore to baseline (n = 6), no change in VEPs (n = 31), and improvement in VEPs (n = 1). Correlation between VEP changes and postoperative visual fields was measured through univariate ordered logistic regression. Improved intraoperative VEP measurements were associated with odds ratio (OR) of visual field improvement of 3.15 (95% confidence interval, 1.15-8.59). Specifically, changes in VEP amplitude were positively associated with visual field improvement with OR of 4.35 (OR, 1.29-14.7). No association was observed between VEPs and other patient or tumor characteristics.

CONCLUSION

Changes in VEP amplitude during endoscopic sellar tumor resection correlate with postoperative visual function. Intraoperative VEP monitoring can serve an important role in preventing postoperative visual field loss.

Short- and long-term outcomes of endoscopically treated superficial non-ampullary duodenal epithelial tumors

BACKGROUND

It is widely recognized that endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is technically challenging and may carry high risks of intraoperative and delayed bleeding and perforation. These adverse events could be more critical than those occurring in other levels of the gastrointestinal tract. Because of the low prevalence of the disease and the high risks of severe adverse events, the curability including short- and long-term outcomes have not been standardized yet.

AIM

To investigate the curability including short- and long-term outcomes of ER for SNADETs in a large case series.

METHODS

This retrospective study included cases that underwent ER for SNADETs at our university hospital between March 2004 and July 2017. Short-term outcomes of ER were measured based on en bloc and R0 resection rates as well as adverse events. Long-term outcomes included local recurrence detected on endoscopic surveillance and disease-specific mortality in patients followed up for ≥ 12 mo after ER.

RESULTS

In the study, 131 patients with 147 SNADETs were analyzed. The 147 ERs consisted of 136 endoscopic mucosal resections (EMRs) (93%) and 11 endoscopic submucosal dissections (ESDs) (7%). The median tumor diameter was 10 mm. The pathology diagnosis was adenocarcinoma (56/147, 38%), high-grade intraepithelial neoplasia (44/147, 30%), or low-grade intraepithelial neoplasia (47/147, 32%). The R0 resection rate was 68% (93/136) in the EMR group and 73% (8/11) in the ESD group, respectively. Cap-assisted EMR (known as EMR-C) showed a higher rate of R0 resection compared to the conventional method of EMR using a snare (78% vs 62%, P = 0.06). No adverse event was observed in the EMR group, whereas delayed bleeding, intraoperative perforation, and delayed perforation in 3, 3, and 5 patients occurred in the ESD group, respectively. One patient with perforation required emergency surgery. In the 43 mo median follow-up period, local recurrence was found in four EMR cases and all cases were treated endoscopically. No patient died due to tumor recurrence.

CONCLUSION

Our findings suggest that ER provides good long-term outcomes in the patients with SNADETs. EMR is likely to become the safe and reliable treatment for small SNADETs.

Clinical outcomes of endoscopic resection for non-ampullary duodenal laterally spreading tumors

BACKGROUND AND AIMS

Non-ampullary duodenal laterally spreading tumors (NAD-LSTs) mimic the morphological features and natural history of colorectal LSTs, even achieving a large size but lacking invasive behavior; thus, they are suited for endoscopic resection (ER). At present, the endoscopic therapeutic approach in NAD-LSTs has not been clearly established. The aim of this study was to evaluate the efficacy and safety of ER for NAD-LSTs and to evaluate the risk factors for delayed perforation after ER of NAD-LSTs.

PATIENTS AND METHODS

A total of 54 patients with 54 NAD-LSTs treated with ER at the Chinese PLA General Hospital between January 2007 and January 2018 were retrospectively analyzed. Data on patient demographic, clinicopathological characteristics of the lesions, outcomes of ER, and results of follow-up endoscopies were collected.

RESULTS

The mean (SD) lesion size was 26.9 mm (8.5). Endoscopic mucosal resection (EMR) was performed in 21 lesions, and endoscopic submucosal dissection (ESD) was performed in 33 lesions. R0 resection was achieved in 93.9% of the ESD group and 38.1% of the EMR group (p = 0.000). Delayed bleeding was noted in two patients. Delayed perforation was identified in four patients. The incidence of delayed perforation showed a significant association with post-ampullary tumor location (p = 0.030). Follow-up endoscopy was performed in all cases with a mean (SD) period of 22.1 months (8.2), and local recurrence was identified in four cases after piecemeal EMR.

CONCLUSIONS

ER of NAD-LSTs is a feasible and less invasive treatment. However, ER of NAD-LSTs is associated with serious adverse events such as delayed perforation, especially in patients with lesions located distal to Vater's ampulla.

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM

To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection (STER) and compare its outcomes in esophageal and cardial submucosal tumors (SMTs) of the muscularis propria (MP) layer.

METHODS

From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal (GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate, residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.

RESULTS

One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus (6.7%), 49 in the middle esophagus (29.7%), 46 in the lower esophagus (27.9%), and 59 in the cardia (35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of 78.7% (128/165) for GI SMTs with an overall complication rate of 21.2% (35/165). All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1% (86/106) and 72.1% (42/59), respectively (P = 0.142), and the complication rates were 19.8% (21/106) and 23.7% (14/59), respectively, (P = 0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.

CONCLUSION

STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.