Staging Early Esophageal Cancer

Staging esophageal cancer provides a standardized measure of the extent of disease that can be used to inform decisions about therapy and guide prognosis. For esophageal cancer, the treatment pathways vary greatly depending on stage of disease, and accurate staging is therefore crucial in ensuring the optimal therapy for each patient. For early esophageal cancer (T1 lesions), endoscopic resection can be curative and simultaneously gives accurate staging of depth of invasion. For tumors invading the submucosa or more advanced disease, comprehensive investigation is required to accurately stage the tumor and assess suitability for curative resection. A combined imaging approach of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) offers complementary diagnostic information and gives the greatest chance of accurate staging. Staging laparoscopy can identify peritoneal disease and small superficial liver lesions that could be missed on CT or PET, and alters management in up to 20 % of patients. Optical diagnostic techniques offer the prospect of further extending the possibilities of endoscopic staging in real time. Optical coherence tomography can image superficial lesions and could provide information on depth of invasion for these lesions. Real-time lymph node analysis using optical diagnostics such as Raman spectroscopy could be used to support immediate endoscopic therapy without waiting for results of cytology or further investigations.

Endotherapy in case of relapse of neoplastic Barrett's esophagus after successful initial endoscopic resection

BACKGROUND

Endotherapy in cases of neoplastic Barrett esophagus (BE) relapse after successful initial endoscopic management is commonly accepted, but few studies analyze this topic and also take into account the metachronous lesions.

AIMS

To evaluate the efficiency of endotherapy in the case of neoplastic BE relapse after successful complete endoscopic eradication of neoplastic BE and metaplastic BE.

METHODS

Retrospective review of medical records was collected in a computerized and prospective manner between 2000 and 2015, in a single tertiary care center. Recurrence was defined by histological presence of high-grade dysplasia or superficial adenocarcinoma at least 6 months after the end of successful initial endotherapy.

RESULTS

Eighteen patients were assessed (1F/17 M). Delay between initial treatment and relapse was 16.6 months (range 6-33). Endotherapy for relapse obtained a sustained and complete remission for 8/18 (44%) patients, with an average endoscopic follow-up of 28 months. The complication rate of endotherapy was 6%. Surgical management was required in 33% (2 pT2N0M0, 2 pTisN0M0, 1 pTm2N0M0 and 1 pTm3N0M0) and salvage radiochemotherapy in 17% (3/18). One patient treated by 6 sessions of ER was considered as a failure given the multiple sessions of endotherapy. Multivariate analysis showed that length of BE (>5 cm), late stenosis adverse events and the quality of vertical margin during initial ER are predictive factors for disease-free survival (p value < 0.01, Hazard Ratio up to 0.076).

CONCLUSION

Endotherapy could be a treatment for management of neoplastic BE relapse, but should be carefully used, with strict follow-up.

Relationship between socioeconomic status and accessibility for endoscopic resection among gastric cancer patients: using National Health Insurance Cohort in Korea: poverty and endoscopic resection

BACKGROUND

Gastric cancer is one of the most common types of cancer among patients in Korea. We measured the inequity in accessibility to endoscopic mucosal/submucosal resection (EMR) for early and curable gastric cancer treatment among different income classes in patients diagnosed from late 2011 to 2013.

METHODS

Data were obtained from the National Health Insurance Cooperation Claim Data from patients diagnosed from late 2011 until the end of 2013, to provide a total of 1,671 patients with newly diagnosed carcinoma in situ of gastric and gastric cancer among 1,025,340 enrollees. Multiple logistic regression analysis was conducted to investigate the associations between independent variables and the rate of treatment with EMR.

RESULTS

Among 1671 gastric cancer patients, 317 (19.0 %) subjects were treated with EMR. The 'lowest' income group was associated with a statistically significant lower rate of EMR treatment [odds ratio (OR) = 0.55, 95 % confidence index (CI) 0.34-0.89] compared to the 'highest' income group. The ORs for the 'low-middle' and 'middle-high' income groups were both higher than for the reference group, although these were not significantly different. According to the subgroup analysis by gender, rate of EMR treatment of 'lowest' income group (OR = 0.37, 95 % CI 0.18-0.74) was significantly lower only among men.

CONCLUSION

In conclusion, we suggest that although universal health insurance in Korea has covered EMR treatment since August 2011, patients from the lowest income group are less likely to receive this treatment. Thus, we need to detect more eligible early-stage gastric cancer and treatment for individuals of low socioeconomic status.

Clinical value of the Integrated Pulmonary Index® during sedation for interventional upper GI-endoscopy: A randomized, prospective tri-center study

BACKGROUND AND STUDY AIMS

The Integrated Pulmonary Index^® (IPI) is a mathematically-determined factor based on parameters of capnography and pulse oximetry, which should enable sensitive detection of impaired respiratory function. Aim was to investigate whether an additional measurement of the IPI during sedation for interventional endoscopy, compared to standard monitoring alone, allows a reduction of sedation-related respiratory depression.

PATIENTS AND METHODS

170 patients with standard monitoring randomly underwent either a blinded recording of capnography (control group, n=87) or capnography, including automated IPI calculation (IPI group, n=83), during deep sedation with midazolam and propofol. The primary endpoint was the maximum decrease of oxygen saturation from the baseline level before sedation. Secondary endpoints: incidence of hypoxemia (SaO₂<90%), other sedation-related complications (apnea rate, bradycardia, hypotension), patient cooperation and satisfaction (VAS).

RESULTS

Mean propofol dose in the IPI group (245±61mg) was comparable to the control group (225±47mg). The average drop of the oxygen saturation in the IPI group (6.5±4.1%) was nearly identical to that of the control group (7.1±4.6%, p=0.44). Apnea episodes >15s was found in 46 patients of the control and 31 of the IPI group (p<0.05). Frequency of occurrence of a drop in pO₂-saturation <90%, bradycardia <50/min or a drop of systolic pressure <90mmHg were not significantly different in both groups. Mechanical ventilation was not required in any case. Patient cooperation and satisfaction were assessed similar in both groups.

CONCLUSION

A clinically appealing advantage of IPI-assessment during deep sedation with midazolam and propofol for interventional endoscopy could not be documented. However, IPI registration was more effective in reducing the incidence of apnea episodes.

Surveillance after endoscopic and surgical resection of colorectal cancer

With the increase in colorectal cancer burden, surveillance following endoscopic and surgical resection is an essential issue. The aim of surveillance programs is improvement of patient survival by early detection of residual tumor tissue or local recurrence, metachronous colorectal tumors, and metastases. Appropriate surveillance should be determined according to this risk of factors. In current guidelines, only surveillance colonoscopy is recommended after endoscopic resection of polyps with high-grade dysplasia, whereas intensive, multimodality surveillance using colonoscopy, radiological imaging and tumor marker measurements is recommended following surgical resection of invasive colorectal cancer. Detailed recommendations, including the timing of surveillance, are described based on high-quality evidence. However, there are still many unresolved issues for which more high-quality evidence is required.

Is radical surgery of an inverted papilloma of the maxillary sinus obsolete? a case report

Background

Sinonasal inverted papilloma is a locally aggressive tumor arising from the Schneiderian membrane which lines the nasal cavity and paranasal sinuses. Aggressive surgical approaches, such as lateral rhinotomy, were used until recently for complete removal of the inverted papilloma. Currently, endoscopic resection is the gold standard in the treatment of inverted papilloma. However, there are situations that justify an open approach. For example there are studies that report a higher postoperative recurrence rate after endonasal endoscopic resection, particularly in the treatment of recurrent diseases. While endoscopic resection performed by an experienced surgeon is definitely a minimally invasive therapy, an open approach is not necessarily associated with functional and aesthetic disadvantages.

This case report describes the treatment of inverted papilloma by an open approach. This has been described before but the new gold standard of endoscopic resection has to be taken into account before any treatment decision is made nowadays.

Case presentation

Contrast-enhanced magnetic resonance imaging of the head and neck area was indicated in a 72-year-old white German man who presented with suspected squamous cell carcinoma of his lower lip. Magnetic resonance imaging additionally revealed a 3×2 cm² polycyclic arranged mucosal thickening with cystic and solid contrast affine shares at the antral laterocaudal area of his right maxillary sinus, extending from his right lateral nasal wall to his maxillary sinus floor.

He received antral polypectomy with medial maxillectomy via a unilateral LeFort I osteotomy approach. His pterygoid plate was preserved. A histological examination demonstrated a tumor composed of hyperplastic squamous epithelium protruding into the stroma (surface epithelial cells grew downward into the underlying supportive tissue), thus producing a grossly convoluted cerebriform appearance. Two weeks later, the patient regained a well-formed maxilla without any restrictions. He has remained disease-free for 25 months following the surgery and surveillance was continued in our tumor clinic.

Conclusions

Endoscopic resection of an inverted papilloma continues to be the gold standard. However, some cases require a radical approach. This does not necessarily increase patient morbidity.

Distant lymph node metastases caused by esophageal cancer invasion to the lamina propria: a case report

Background

Pathological examination after endoscopic submucosal dissection revealed that a 62-year-old male had esophageal squamous cell carcinoma with lamina propria mucosal invasion and lymphatic permeation.

Case presentation

The patient underwent subtotal esophagectomy and reconstruction as an additional therapy. At 3 years and 4 months after esophagectomy, enlargement of abdominal para-aortic lymph nodes metastases was detected by computed tomography scanning. A total of 50.4 Gy of radiation and two cycles of 5-fluorouracil plus cisplatin were administered. The lymph node metastases were markedly reduced by chemoradiotherapy; however, at 1 year and 1 month later (4 years and 5 months after esophagectomy), left adrenal gland recurrence was found. Although resection was performed, the patient died from cancer progression at 5 years and 4 months after esophagectomy.

Conclusions

This case demonstrates that esophageal squamous cell carcinoma with invasion to the lamina propria and lymphatic permeation has the potential to cause distant metastases.

A retrospective study of endoscopic resection for 368 patients with early esophageal squamous cell carcinoma or precancerous lesions

BACKGROUND

To retrospectively investigate the clinicopathological features and prognosis of early esophageal squamous cell neoplasm (ESCN) treated with endoscopic resection (ER), especially, to compare the prognosis in patients with sm2 cancer and non-sm2 cancer.

METHODS

From 2007 to 2013, 368 patients were included in our analysis.

RESULTS

The patients were 252 (68.5 %) men and 116 (31.5 %) women with a median age of 61 (range 16-84 years) years. Hyperplasia, mild dysplasia, moderate dysplasia, severe dysplasia, m1, m2, m3, sm1, and sm2 were diagnosed in 47 (12.8 %), 27 (7.3 %), 34 (9.2 %), 61 (16.6 %), 54 (14.7 %), 38 (10.3 %), 63 (17.1 %), 12 (3.3 %), and 32 (8.7 %) cases. The mean (range) follow-up time was 29 (0-84) months. The cumulative overall 1-, 3-, and 5-year metachronous esophageal lesion rates were 4.1, 12.9, and 32.6 %. The incidence of lymph node or distant metastasis was 1.54 % in m3, 6.25 % in sm2, and 0 in other subgroups. The overall 1-, 3-, and 5-year survival rates were 99.5, 97.3, and 87.5 %. There was significant difference between sm2 and non-sm2 patients in metastatic rate (P = 0.021); however, no difference existed between m3 patients and sm2 patients (P = 0.252). The difference of metachronous esophageal lesion (P = 0.401) and survival (P = 0.634) between sm2 and non-sm2 patients was not obvious.

CONCLUSIONS

Our study showed that ER was an effective and relatively safe treatment for superficial ESCN. ER is still appropriate in select sm2 patients. To monitor the second primary cancer in sm2 is necessary during the follow-up.

Evaluation and Endoscopic Management of Esophageal Submucosal Tumor

Submucosal tumors (SMTs) originate from tissues that constitute the submucosal layer and muscularis propria, and are covered by normal mucosa. Esophageal SMTs are rare, accounting for <1% of all esophageal tumors. However, the recent widespread use of endoscopy has led to a rapid increase in incidental detection of SMTs in Korea. Esophageal SMTs are benign in ≥90% of cases, but the possibility of malignancies such as gastrointestinal stromal tumor and malignant leiomyosarcoma still exists. Therefore, patients undergo resection in the presence of symptoms or the possibility of a malignant tumor. For resection of esophageal SMTs, surgical resection was the only option available in case of possible malignancy, but minimally invasive surgery by endoscopic resection is becoming more preferable to surgical resection with the development of endoscopic ultrasonography, endoscopic techniques, and other devices.

Short- and long-term outcomes of endoscopic resection of rectal neuroendocrine tumours: analyses according to the WHO 2010 classification

OBJECTIVE

Although the World Health Organisation (WHO) defined a novel classification of gastroenteropancreatic neuroendocrine tumours (NETs) in 2010, indications for endoscopic resection of rectal NETs in the guidelines were based on evidence accumulated for carcinoid tumours defined by a previous classification. This study was designed to clarify indications for endoscopic resection of rectal NETs corresponding to the new WHO classifications.

MATERIAL AND METHODS

One hundred-seventy rectal NETs resected endoscopically from April 2001 to March 2012 were histologically re-classified according to the WHO 2010 criteria. The clinicopathological features of these lesions were analysed, and the short- and long-term outcomes of endoscopic resection were evaluated.

RESULTS

Of the 170 rectal NETs, 166 were histopathologically diagnosed as NET G1 and four as NET G2. Thirty-eight tumours (22.4%) were positive for lymphovascular invasion, a percentage higher than expected. Although the curative resection rate was low (65.3%), en bloc (98.8%) and complete (85.9%) resection rates were high. Modified endoscopic mucosal resection (88.0%) and endoscopic submucosal dissection (92.2%) resulted in significantly higher complete resection rates than conventional endoscopic mucosal resection (36.4%). No patient experienced tumour recurrence, despite the low curative resection rate.

CONCLUSION

Despite the low curative resection rate, prognosis after endoscopic resection of rectal NETs was excellent. Prospective large-scale, long-term studies are required to determine whether NET G2 and tumours >1 cm should be included in the indication for endoscopic resection and whether tumours with lymphovascular invasion can be followed up without additional surgery.

Safety of Target-Controlled Propofol Infusion by Gastroenterologists in Patients Undergoing Endoscopic Resection

BACKGROUND

A target-controlled infusion (TCI) of a propofol system uses a pharmacokinetic model to achieve and maintain a selected target blood propofol concentration. The aim of this study was to assess whether the propofol TCI system could be safely used by gastroenterologists in patients undergoing endoscopic resection including endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) compared with a manually controlled infusion (MCI) system.

METHODS

A total of 431 patients undergoing therapeutic endoscopy (178 ESD and 253 EMR) were consecutively included from November 2011 to August 2014. The patients were divided into the MCI (271) and TCI (160) propofol infusion groups. We compared adverse event rates in MCI and TCI groups and assessed independent risk factors for adverse events.

RESULTS

The total sedation-related adverse event rate was 5.8 % (25/431). Most of the events were minor, and the rate of major events was 0.5 % (2/431). There was no significant difference in adverse event rate between the MCI and TCI groups [5.5 % (15/271) vs. 6.3 % (10/160); P = 0.759]. In univariate analysis, the propofol infusion time was significantly associated with adverse events (94.88 vs. 59.45 min, P = 0.017). In the multivariate analysis, there were no significant factors associated with adverse events. TCI was not an independent risk factor for adverse events despite the fact that the TCI had a longer duration of infusion and higher total infusion dose (95 % CI, 0.343-2.216; P = 0.773).

CONCLUSIONS

TCI of propofol by gastroenterologists may provide safe sedation in patients undergoing ESD and EMR under careful respiratory monitoring.

Risk stratification and predictive risk-scoring model for lymph node metastasis in early gastric cancer

BACKGROUND

We are increasingly experiencing difficulty in deciding whether to perform gastrectomy after noncurative endoscopic resection of early gastric cancer (EGC) for patients at high risk for surgery. If the differences in risk for lymph node metastasis (LNM) on the basis of noncurative status are understood, the decision becomes easier. The present study aimed to stratify the LNM risk and develop and validate a risk-scoring model for predicting LNM.

METHODS

By retrospectively reviewing 3131 patients with solitary EGC who underwent gastrectomy with lymphadenectomy at our institution between July 1997 and May 2013, LNM risk was stratified and a risk-scoring model was developed on the basis of the identified independent risk factors for LNM. The scoring was validated using 352 other surgically resected EGC cases. The discriminatory accuracy of the scoring was measured by area under receiver operating characteristic curve (AUROC).

RESULTS

LNM was detected in 386 of 3131 cases. LNM risk in each subgroup, stratified by the identified independent risk factors, such as tumor size, depth, histological type, ulcerative findings, and lymphovascular involvement, considerably varied from 0 % to >50 % even among the current guidelines' noncurative subgroups. An 11-point scoring model was built, and AUROCs were 0.84 (95 % confidence interval, 0.82-0.86) and 0.82 (0.75-0.88) in the development and validation sets, respectively.

CONCLUSIONS

The present study revealed detailed LNM risk stratification data, and developed and validated an 11-point scoring model.

Endoscopic Submucosal Dissection for Early Gastric Cancers with Uncommon Histology

Endoscopic submucosal dissection (ESD) enables en bloc curative resection of early gastric cancers (EGCs) with a negligible risk of lymph node metastasis (LNM). Although ESD for EGCs with absolute and expanded indications is safe, the results differ between EGCs with specialized and common histologies. EGC with papillary adenocarcinoma is a differentiated-type adenocarcinoma. At present, it is treated with ESD according to the same criteria as other differentiated-type adenocarcinomas. The LNM rate under the current indication criteria is high, and over half of the patients who undergo ESD as a primary treatment for EGC with papillary adenocarcinoma achieve an out-of-ESD result. Gastric carcinoma with lymphoid stroma in EGC has a low LNM rate and a favorable outcome, despite deep submucosal invasion. Patients with this gastric cancer subtype may be good candidates for ESD, even with deep submucosal invasion. Large-scale prospective multi-center studies with longer follow-up periods are needed to set proper ESD criteria for these tumors. Clinicians should be aware of these disease entities and ESD should be more carefully considered for EGCs with papillary adenocarcinoma and gastric carcinoma with lymphoid stroma.

A Rare Case of Solitary Peutz Jeghers Type Hamartomatous Duodenal Polyp with Dysplasia!

Solitary Peutz Jeghers (SPJ) type hamartomatous polyp is a rare and separate entity from classic Peutz Jeghers syndrome (PJS). A hamartomatous polyp without associated mucocutaneous pigmentations, any other gastrointestinal polyp or a family history of PJS is diagnosed as a SPJ type polyp. We described a case of 22-year-old young man in whom solitary duodenal polyp was incidentally detected and resected. Histopathological examination revealed PJ type hamartomatous polyp with foci of adenomatous and moderate dysplastic change. Very few cases of solitary duodenal PJ type hamartomatous polyps with malignant transformation have been reported. They can be treated with endoscopic or surgical resection. Endoscopic ultrasound can give an idea about the depth of involvement. This is a rare case of duodenal solitary PJ polyp with dysplasia in a young patient.

Update on Difficult Polypectomy Techniques

Endoscopists often encounter colon polyps that are technically difficult to resect. These lesions traditionally were managed surgically, with significant potential morbidity and mortality. Recent advances in endoscopic techniques and instruments have allowed endoscopists to safely and effectively remove colorectal lesions with high technical and clinical success and potentially avoid invasive surgery. Endoscopic mucosal resection (EMR) has gained acceptance as the first-line therapy for large colorectal lesions. Endoscopic submucosal dissection (ESD) has been reported to be associated with higher rate of en bloc resection and less risk of short-time recurrence, but with an increased risk of adverse events. Therefore, the role of colorectal ESD should be restricted to lesions with high-risk morphologic features of submucosal invasion. In this article, we review the recent literature on the endoscopic management of difficult colorectal neoplasms.

Interventional Therapy of Esophageal Cancer

Esophageal cancer (EC) is the fourth leading cause of cancer death in China. Despite a lot of advances in diagnosis and therapy, the survival rate of patients with EC is low. There is urgent need for a variety of methods and techniques to improve the survival time and alleviate the lesions of EC. Nowadays, alternative and less invasive approaches to the treatment of ECs are being identified. Here, we review several main interventional methods at different stages of EC, including endoscopic resection, stent placement, arterial infusion, photodynamic therapy, and radiofrequency ablation. This review will focus on the indications, methods, clinical outcomes, and complications of these methods, which may help guide the way forward.

Endoscopic resection for duodenal subepithelial tumors: a single-center experience

BACKGROUND

Subepithelial tumors (SETs) in the gastrointestinal tract are often incidentally found during endoscopic examinations. Although the utility and safety of endoscopic resection (ER) of SETs in the esophagus and stomach have been described, data about the ER of duodenal SETs remain scant. Therefore, we aimed to investigate the clinical outcomes associated with the ER of duodenal SETs and to assess possible predictive factors for incomplete resection.

METHODS

We conducted a retrospective observational study of 62 patients (64 lesions) that underwent ER of duodenal SETs between June 2005 and December 2015 at the Pusan National University Hospital. The therapeutic outcomes from ER and procedure-related complications were analyzed.

RESULTS

Endoscopic mucosal resection (EMR) was performed in 38 tumors, EMR with a ligation device (EMR-L) in 18 and endoscopic submucosal dissection (ESD) in 8. The overall en bloc resection and complete ER rates were 96.9 % (62/64) and 100 % (64/64), respectively. The complete pathologic resection rate was 76.6 % (49/64). Multivariate logistic regression analyses determined that the macroscopic type (Yamada type I or II; odds ratio [OR] 6.460, 95 % confidence interval [CI] 1.569-37.458, p = 0.027) and the treatment method (ESD; OR 7.178, 95 % CI 1.291-39.323, p = 0.024) were independently associated with incomplete pathologic resection. The procedure-related bleeding and perforation rates were 6.3 % and 4.7 %, respectively. No recurrences were observed in patients who had undergone complete ER at a median follow-up period of 20 months (range 6-112 months).

CONCLUSION

ER is an effective, safe, and feasible treatment for duodenal SETs, especially when the SET is located in the deep mucosal layer and/or the submucosal layer.

[Solitary Neurofibroma of the Sigmoid Colon Presenting as a Subepithelial Tumor Successfully Removed by Endoscopic Resection]

Neurofibromas are benign, slow-growing nerve sheath tumors of the peripheral nervous system, arising from Schwann cells, and classically associated with neurofibromatosis type 1 (Nf1, von Recklinghausen's disease). They occur rarely in the gastro-intestinal tract as isolated neoplasms, outside the classical clinical feature of neurofibromatosis. We herein present an isolated colonic neurofibroma without any systemic signs of neurofibromatosis. A 59-year-old female came to our hospital for constipation. On physical examination, general appearance showed no definite skin lesions. A subepithelial tumor measuring 0.8 cm was detected at the distal descending colon on colonoscopy. The lesion was removed completely by endoscopic resection. Microscopic examination showed proliferation of spindle cells in the mucosa and infiltration of inflammatory cells. Immunohistochemical staining was positive for S-100 protein. The above morphological and immunohistochemical characteristics were consistent with a diagnosis of a solitary neurofibroma of the sigmoid colon.

Additive treatment improves survival in elderly patients after non-curative endoscopic resection for early gastric cancer

BACKGROUND AND STUDY AIMS

Endoscopic resection (ER) is accepted as a curative treatment option for selected cases of early gastric cancer (EGC). Although additional surgery is often recommended for patients who have undergone non-curative ER, clinicians are cautious when managing elderly patients with GC because of comorbid conditions. The aim of the study was to investigate clinical outcomes in elderly patients following non-curative ER with and without additive treatment.

PATIENTS AND METHODS

Subjects included 365 patients (>75 years old) who were diagnosed with EGC and underwent ER between 2007 and 2015. Clinical outcomes of three patient groups [curative ER (n = 246), non-curative ER with additive treatment (n = 37), non-curative ER without additive treatment (n = 82)] were compared.

RESULTS

Among the patients who underwent non-curative ER with additive treatment, 28 received surgery, three received a repeat ER, and six experienced argon plasma coagulation. Patients who underwent non-curative ER alone were significantly older than those who underwent additive treatment. Overall 5-year survival rates in the curative ER, non-curative ER with treatment, and non-curative ER without treatment groups were 84, 86, and 69 %, respectively. No significant difference in overall survival was found between patients in the curative ER and non-curative ER with additive treatment groups. The non-curative ER groups were categorized by lymph node metastasis risk factors to create a high-risk group that exhibited positive lymphovascular invasion or deep submucosal invasion greater than SM2 and a low-risk group without risk factors. Overall 5-year survival rate was lowest (60 %) in the high-risk group with non-curative ER and no additive treatment.

CONCLUSIONS

Elderly patients who underwent non-curative ER with additive treatment showed better survival outcome than those without treatment. Therefore, especially with LVI or deep submucosal invasion, additive treatment is recommended in patients undergoing non-curative ER, even if they are older than 75 years.

Safety of endoscopic resection for duodenal subepithelial lesions with wound closure using clips and an endoloop: an analysis of 68 cases

BACKGROUND

Endoscopic removal of a duodenal lesion is still considered to be a challenging procedure that can be fraught with potentially serious complications, specifically perforation or delayed bleeding. This study was to assess the safety of endoscopic resection for duodenal subepithelial lesions (SELs) with wound closure using clips and an endoloop.

METHODS

From October 2010 to July 2015, a total of 68 consecutive patients with duodenal SELs were treated with endoscopic resection with wound closure using clips and an endoloop. The main outcome measures considered were the incidence of complete resection, perioperative perforation, delayed perforation, delayed bleeding, residual lesions, and lesion recurrence.

RESULTS

Complete resection was successfully achieved for all 68 patients. The median lesion size was 1.7 cm. The median procedure time was 62 min. The mean hospital stay was 5.5 days. During the procedure, five patients developed perioperative perforations (7.4 %) and no patients developed delayed bleeding, delayed perforation, or other serious complications. The five patients with perioperative perforations recovered after conservative treatment. The perioperative perforation rate was significantly higher for lesions originating in the muscularis propria layer (18.2 %) than in the submucosal layer (2.2 %; p < 0.05). No residual or recurrent lesions were detected during the follow-up period (median: 27 months).

CONCLUSIONS

Endoscopic resection with wound closure using clips and an endoloop is an effective and reasonably safe therapeutic method for treating/removing duodenal SELs when managed by an experienced endoscopic team, and it can provide an alternative treatment option for patients with duodenal SELs.

Is the recent WHO histological classification for gastric cancer helpful for application to endoscopic resection?

BACKGROUND

Endoscopic resection is performed in undifferentiated-type early gastric cancer (UD-EGC), including poorly differentiated (PD) adenocarcinoma and signet ring cell (SRC) carcinoma. We previously found that different approaches are needed for PD adenocarcinoma and SRC carcinoma for curative resection. However, according to the 2010 WHO classification, diffuse-type PD adenocarcinoma and SRC carcinoma are categorized in the "poorly cohesive carcinomas." Thus, we assessed whether the WHO classification is helpful when endoscopic resection is performed for treatment of UD-EGC.

METHODS

We analyzed clinicopathological features of 1295 lesions with SRC carcinoma and PD adenocarcinoma treated by open surgery. We recategorized them into intestinal-type PD adenocarcinomas and poorly cohesive carcinomas (SRC carcinoma, diffuse-type PD adenocarcinoma). We also recategorized 176 lesions treated by endoscopic resection into intestinal-type PD adenocarcinomas and poorly cohesive carcinomas.

RESULTS

According to the open surgery data, the rates of lymph node metastasis (LNM) and lymphovascular invasion were significantly lower in SRC carcinoma than in diffuse-type and intestinal-type PD adenocarcinomas. The rates of LNM and lymphovascular invasion were significantly higher in diffuse-type PD adenocarcinoma than in SRC carcinoma. Endoscopic resection data showed no recurrence if the carcinoma was curatively resected. However, the commonest cause of noncurative resection was different in SRC carcinoma and PD adenocarcinoma. A positive lateral margin was the commonest cause in SRC carcinoma versus a positive vertical margin in both intestinal-type and diffuse-type PD adenocarcinoma.

CONCLUSIONS

The clinical behavior differs in diffuse-type PD adenocarcinoma and SRC carcinoma. On the basis of LNM and outcomes of endoscopic resection, the recent WHO classification may not be helpful when endoscopic resection is performed for treatment of UD-EGC.

Endoscopic en bloc resection of an exophytic gastrointestinal stromal tumor with suction excavation technique

Here, we report the first successful endoscopic resection of an exophytic gastrointestinal stromal tumor (GIST) using a novel perforation-free suction excavation technique. A 49-year-old woman presented for further management of a gastric subepithelial tumor on the lesser curvature of the lower body, originally detected via routine upper gastrointestinal endoscopy. Abdominal computed tomography and endoscopic ultrasound showed a 4-cm extraluminally protruding mass originating from the muscularis propria layer. The patient firmly refused surgical resection owing to potential cardiac problems, and informed consent was obtained for endoscopic removal. Careful dissection and suction of the tumor was repeated until successful extraction was achieved without serosal injury. We named this procedure the suction excavation technique. The tumor’s dimensions were 3.5 cm × 2.8 cm × 2.5 cm. The tumor was positive for C-KIT and CD34 by immunohistochemical staining. The mitotic count was 6/50 high-power fields. The patient was followed for 5 years without tumor recurrence. This case demonstrated the use of endoscopic resection of an exophytic GIST using the suction excavation technique as a potential therapy without surgical resection.

Comparison of pathological diagnosis between tissue biopsy and endoscopic resection of colon polyps

AIM: To evaluate the discrepancy of pathological diagnosis between tissue biopsy and resection of colon polyps, and explore the main influencing factors to improve the accuracy of biopsy methods.

METHODS: This study retrospectively analyzed 161 colon polyps from 142 patients who underwent polyp resection at our hospital (patients with polyps of at least 1.0 cm in diameter). The discrepancy in the pathological diagnosis between endoscopic biopsy and resected tissues of colon polyps was evaluated. Factors that contributed to such discrepancy were analyzed.

RESULTS: The concordance rate of pathological diagnosis between endoscopic biopsy and resection was 51% (82/161), and the discrepancy rate was 49% (79/161). The lesion size was the main factor that undermined the diagnostic accuracy of biopsy (1.0-1.9 cm, the discrepancy rate was 42%; ≥2.0 cm, the discrepancy rate was 65%; P < 0.05).

CONCLUSION: The pathological diagnosis by endoscopic biopsy of colon polyps is of limited accuracy, especially in larger diameter polyps.

Efficacy and safety of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors: a systematic review and meta-analysis

BACKGROUND

In recent years, submucosal tunneling endoscopic resection (STER) has emerged as a novel therapeutic endoscopic technique for upper gastrointestinal submucosal tumors (SMTs). The aim of this study was to evaluate the safety and efficacy of STER for upper gastrointestinal SMTs.

METHODS

A systematic search of both English and Chinese databases was performed until November 15, 2015. Complete resection and en bloc resection rates were considered the primary outcome measures. Prevalence of complications was considered the secondary outcome measure. A random-effects model was used to generate conservative estimates of the prevalence of the main outcome variables. All data analyses were performed using Meta-Analyst software (version beta 3.13).

RESULTS

A total of 28 studies were included in the final meta-analysis. The pooled complete resection and en bloc resection rates were 97.5 % (95 % CI 96.0-98.5 %) and 94.6 % (95 % CI 91.5-96.7 %), respectively. The common complications associated with STER were air leakage symptoms and perforation. The pooled prevalence of air leakage symptoms was 14.8 % (95 % CI 10.5-20.5 %) for subcutaneous emphysema and pneumomediastinum, 6.1 % (95 % CI 4.0-9.0 %) for pneumothorax and 6.8 % (95 % CI 4.7-9.6 %) for pneumoperitoneum. Additionally, the pooled prevalence of perforation was 5.6 % (95 % CI 3.7-8.2 %). Only a few cases of bleeding were reported in two studies.

CONCLUSIONS

STER is a highly feasible and safe treatment option for upper gastrointestinal SMTs.