Endoscopic treatments for small gastric subepithelial tumors originating from muscularis propria layer

Minimally invasive endoscopic resection has become an increasingly popular method for patients with small (less than 3.5 cm in diameter) gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer. Currently, the main endoscopic therapies for patients with such tumors are endoscopic muscularis excavation, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection. Although these endoscopic techniques can be used for complete resection of the tumor and provide an accurate pathological diagnosis, these techniques have been associated with several negative events, such as incomplete resection, perforation, and bleeding. This review provides detailed information on the technical details, likely treatment outcomes, and complications associated with each endoscopic method for treating/removing small gastric SETs that originate from the MP layer.

Neutrophil infiltration and the distribution of intestinal metaplasia is associated with metachronous gastric cancer following endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) of early gastric cancer is a minimally invasive procedure. However, the risk for metachronous cancers after successful cancer treatment remains high and the risk factors for metachronous cancers have not been elucidated.

OBJECTIVE

To evaluate the risk factors for metachronous gastric cancers after ESD with a long-term follow-up.

METHODS

A total of 155 consecutive patients (119 men, 36 women, mean age 68.9 years) were treated with ESD between September 2000 and September 2009. Biopsy specimens were obtained from the greater curvature of the antrum and middle corpus to evaluate gastric mucosal status, including Helicobacter pylori, intestinal metaplasia (IM) and neutrophil infiltration (NI) before ESD. Follow-up endoscopy after ESD was scheduled at two and six months, one year and annually thereafter. H pylori eradication was recommended when possible.

RESULTS

The median follow-up period was 4.2 years. Metachronous gastric cancers were found in 23 of 155 patients (3.5% per year). No local recurrences were observed. The cumulative incidence of metachronous gastric cancer was significantly high in IM and NI in the corpus (P=0.0093 and P=0.0025, respectively [log-rank test]). The ORs for IM and NI in the corpus were 2.65 and 3.06, respectively, according to the Cox proportional hazards model (P=0.024 and P=0.0091, respectively).

CONCLUSIONS

The presence of IM and NI in the corpus was closely related to the development of metachronous gastric cancer after ESD.

PRISMA-Extracapsular Dissection Versus Superficial Parotidectomy in Treatment of Benign Parotid Tumors: Evidence From 3194 Patients

Benign parotid tumor is one of the most common neoplasms in head and neck region. Its therapeutic methods have been debatable topics over the past 100 years. Recently, some surgeons suggest that extracapsular dissection (ECD) instead of superficial parotidectomy (SP) for treatment of benign parotid tumor. This study aimed to compare ECD with SP in the treatment of benign parotid tumors by a meta-analysis.We searched Cochrane Library, PubMed, Embase, Ovid, and Web of Science databases on February 14, 2015 for studies that assessed clinical outcomes of SP and ECD as surgical techniques for the management of benign parotid tumors. Outcome data were evaluated by pooled risk ratio (RR) and corresponding 95% confidence interval (CI).After serious scrutiny, a total of 14 cohort studies with 3194 patients were included in this meta-analysis. The pooled RR revealed that there were no significant difference in tumor recurrence rate between ECD and SP (fixed-effect model: RR = 0.71, 95% CI = 0.40-1.27, P = 0.249; random-effect model: RR = 0.67, 95% CI = 0.38-1.23, P = 0.197). However, there were significantly lower incidences of transient facial nerve dysfunction (FND), permanent FND, and Frey's syndrome in patients of ECD group compared with SP group.ECD might be a good choice in treatment of the benign parotid tumor that were mobile, small, located in superficial lobe and without adhesion to facial nerve; ECD should be performed by the experienced surgeons with ability of dissection facial nerve, who should perform SP if tumor is found adhere to facial nerve during an operation; and a multicenter randomized control trial study is necessary to decide the optimal treatment of benign parotid tumor.

Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection

AIM: To compare the safety and efficacy of carbon dioxide (CO₂) and air insufflation during gastric endoscopic submucosal dissection (ESD).

METHODS: This study involved 116 patients who underwent gastric ESD between January and December 2009. After eliminating 29 patients who fit the exclusion criteria, 87 patients, without known pulmonary dysfunction, were randomized into the CO₂ insufflation (n = 36) or air insufflation (n = 51) groups. Standard ESD was performed with a CO₂ regulation unit (constant rate of 1.4 L/min) used for patients undergoing CO₂ insufflation. Patients received diazepam for conscious sedation and pentazocine for analgesia. Transcutaneous CO₂ tension (PtcCO₂) was recorded 15 min before, during, and after ESD with insufflation. PtcCO₂, the correlation between PtcCO₂ and procedure time, and ESD-related complications were compared between the two groups. Arterial blood gases were analyzed after ESD in the first 30 patients (12 with CO₂ and 18 with air insufflation) to assess the correlation between arterial blood CO₂ partial pressure (PaCO₂) and PtcCO₂.

RESULTS: There were no differences in respiratory functions, median sedative doses, or median procedure times between the groups. Similarly, there was no significant difference in post-ESD blood gas parameters, including PaCO₂, between the CO₂ and air groups (44.6 mmHg vs 45 mmHg). Both groups demonstrated median pH values of 7.36, and none of the patients exhibited acidemia. No significant differences were observed between the CO₂ and air groups with respect to baseline PtcCO₂ (39 mmHg vs 40 mmHg), peak PtcCO₂ during ESD (52 mmHg vs 51 mmHg), or median PtcCO₂ after ESD (50 mmHg vs 50 mmHg). There was a strong correlation between PaCO₂ and PtcCO₂ (r = 0.66; P < 0.001). The incidence of Mallory-Weiss tears was significantly lower with CO₂ insufflation than with air insufflation (0% vs 15.6%, P = 0.013). CO₂ insufflation did not cause any adverse events, such as CO₂ narcosis or gas embolisms.

CONCLUSION: CO₂ insufflation during gastric ESD results in similar blood gas levels as air insufflation, and also reduces the incidence of Mallory-Weiss tears.

Endoscopic and Oncologic Outcomes of Endoscopic Resection for Superficial Esophageal Neoplasm

BACKGROUND/AIMS

Endoscopic resection (ER) of superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ER for SEN to determine its feasibility and effectiveness.

METHODS

Subjects who underwent ER for SEN at Asan Medical Center between December 1996 and December 2010 were eligible. The clinical features of patients and tumors, histopathological characteristics, adverse events, ER results and survival were investigated.

RESULTS

A total of 129 patients underwent ER for 147 SENs. En bloc resection (EnR) was performed in 118 lesions (80.3%). Complete resection (CR) was accomplished in 128 lesions (86.5%), and curative resection (CuR) was performed in 118 lesions (79.7%). The EnR, CR, and CuR rates were significantly greater in the endoscopic submucosal dissection group when compared to those in the endoscopic resection group. Adverse events occurred in 22 patients (17.1%), including bleeding (n=2, 1.6%), perforation (n=12, 9.3%), and stricture (n=8, 6.2%). Local tumor recurrence occurred in 2.0% of patients during a median follow-up of 34.8 months. The 5-year overall and disease-specific survival rates were 94.0% and 97.5%, respectively.

CONCLUSIONS

ER is a feasible and effective method for the treatment of SEN as indicated by favorable clinical outcomes.

Useful strategies to prevent severe stricture after endoscopic submucosal dissection for superficial esophageal neoplasm

The minimal invasiveness of endoscopic submucosal dissection (ESD) prompted us to apply this technique to large-size early esophageal squamous cell carcinoma and Barrett’s adenocarcinoma, despite the limitations in the study population and surveillance duration. A post-ESD ulceration of greater than three-fourths of esophageal circumference was advocated as an important risk factor for refractory strictures that require several sessions of dilation therapy. Most of the preoperative conditions are asymptomatic, but dilatation treatment for dysphagia associated with the stricture has potential risks of severe complications and a worsening of quality of life. Possible mechanisms of dysphasia were demonstrated based on dysmotility and pathological abnormalities at the site: (1) delayed mucosal healing; (2) severe inflammation and disorganized fibrosis with abundant extracellular matrices in the submucosa; and (3) atrophy in the muscularis proper. However, reports on the administration of anti-scarring agents, preventive dilation therapies, and regenerative medicine demonstrated limited success in stricture prevention, and there were discrepancies in the study designs and protocols of these reports. The development and consequent long-term assessments of new prophylactic technologies on the promotion of wound healing and control of the inflammatory/tumor microenvironment will require collaboration among various research fields because of the limited accuracy of preoperative staging and high-risk of local recurrence.

Endoscopic submucosal dissection for early gastric cancer with undifferentiated-type histology: A meta-analysis

AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) with undifferentiated-type histology.

METHODS: A systematic literature review was conducted using the core databases. Complete resection, curative resection, en bloc resection, recurrence and adverse event rate were extracted and analyzed. A random effect model was applied. The methodological quality of the enrolled studies was assessed using the Newcastle-Ottawa Scale. Publication bias was evaluated using a funnel plot, the trim and fill method, Egger’s test, and a rank correlation test.

RESULTS: Fourteen retrospective studies between 2009 and 2014 were identified (972 EGC lesions with undifferentiated-type histology). The total en bloc and complete resection rates were estimated as 92.1% (95%CI: 87.4%-95.2%) and 77.5% (95%CI: 69.3%-84%), respectively. The total curative resection rate was 61.4% (95%CI: 44.5%-75.9%). The overall recurrence rate was 7.6% (95%CI: 3.4%-16%). Limited to histologically diagnosed expanded-criteria lesions, the en bloc and complete resection rates were 91.2% and 85.6%, respectively. The curative resection rate was 79.8%.

CONCLUSION: In this analysis, ESD is a technically feasible treatment modality for EGC with undifferentiated-type histology. Long-term studies are needed to confirm these therapeutic outcomes.

Is endoscopic submucosal dissection safe for papillary adenocarcinoma of the stomach?

AIM: To identify the clinicopathological predictors of lymph node (LN) metastasis and evaluate the outcomes of endoscopic submucosal dissection (ESD) in papillary adenocarcinoma-type early gastric cancers (EGCs).

METHODS: From January 2005 to May 2013, 49 patients who underwent surgical operation and 24 patients who underwent ESD for papillary adenocarcinoma-type EGC were enrolled to identify clinicopathological characteristics and predictive factors of LN metastasis and to evaluate the outcomes of ESD for papillary adenocarcinoma-type EGC.

RESULTS: Most papillary adenocarcinoma-type EGCs were located in the lower third of the stomach and had an elevated macroscopic shape. The overall prevalence of LN metastasis was 18.3% (9/49). The presence of lymphovascular invasion was found to be a predictor of LN metastasis (P = 0.016). According to current indication criteria of ESD, 6 and 11 of the 49 patients had absolute and expanded indications for ESD, respectively. Two patients (11.8%) with expanded indication for ESD had LN metastasis. Of the 24 patients who underwent ESD, 13 (54%) achieved out-of-ESD indication, with 9 of those 13 patients undergoing surgical operation due to non-curative resection.

CONCLUSION: The use of ESD should be carefully considered for papillary adenocarcinoma-type EGC with suspected ESD indication after pre-treatment work-up because of the higher frequency of LN metastasis and additional surgeries.

Bio-sheet graft therapy for artificial gastric ulcer after endoscopic submucosal dissection: an animal feasibility study

BACKGROUND

Various bio-sheet grafts have been attempted either to accelerate healing of artificial ulcers or to prevent adverse events after endoscopic submucosal dissection (ESD), but neither prospective nor mechanistic studies were available.

OBJECTIVE

To evaluate the substantial effect of a bio-sheet graft on artificial ulcer healing and its feasibility as an endoscopic treatment modality.

DESIGN

Preclinical, in vivo animal experiment and proof-of-concept study.

SETTING

Animal laboratory.

SUBJECTS

Three mini-pigs, Sus scrofa, mean age 14 months.

INTERVENTION

Multiple ulcers sized 2.5 cm in diameter were generated by ESD in 3 mini-pigs and were assigned randomly into the following 3 groups; control group, bio-sheet group, or combination (bio-sheet plus drug) group. Bio-sheet grafts or bio-sheet plus drug combinations were applied on the artificial ulcers immediately after the ESD.

MAIN OUTCOME MEASUREMENTS

Feasibility and efficacy of endoscopic bio-sheet graft therapy for the management of artificial ulcers and the evaluation of healing conditions based on histology changes in the remaining gastric bed tissues harvested from the stomachs.

RESULTS

Thirty-three ESD specimens were obtained. On an image analysis of the ratio of healed area in the remaining gastric bed tissue compared with the matched dissected gastric mucosa, the control group showed the most significant improvement in healing activity among the 3 groups (P < .05), whereas the severity of inflammation in the remaining ulcer tissue was significantly attenuated in bio-sheet and combination groups (P < .05).

LIMITATIONS

Animal model.

CONCLUSION

Although the bio-sheet grafts provided physical protection from gastric acid attack as reflected in the attenuated inflammation on the ulcer beds, unexpected delayed ulcer healing was noted in the bio-sheet graft group because of its physical hindrance of the healing process.

Comparison of the efficacy and safety of sedation between dexmedetomidine-remifentanil and propofol-remifentanil during endoscopic submucosal dissection

AIM: To compare the efficacy and safety of sedation protocols for endoscopic submucosal dissection (ESD) between dexmedetomidine-remifentanil and propofol-remifentanil.

METHODS: Fifty-nine patients scheduled for ESD were randomly allocated into a dexmedetomidine-remifentanil (DR) group or a propofol-remifentanil (PR) group. To control patient anxiety, dexmedetomidine or propofol was infused to maintain a score of 4-5 on the Modified Observer’s Assessment of Alertness/Sedation scale. Remifentanil was infused continuously at a rate of 6 μg/kg per hour in both groups. The ease of advancing the scope into the throat, gastric motility grading, and satisfaction of the endoscopist and patient were assessed. Hemodynamic variables and hypoxemic events were compared to evaluate patient safety.

RESULTS: Demographic data were comparable between the groups. The hemodynamic variables and pulse oximetry values were stable during the procedure in both groups despite a lower heart rate in the DR group. No oxygen desaturation events occurred in either group. Although advancing the scope into the throat was easier in the PR group (“very easy” 24.1% vs 56.7%, P = 0.010), gastric motility was more suppressed in the DR group (“no + mild” 96.6% vs 73.3%, P = 0.013). The endoscopists felt that the procedure was more favorable in the DR group (“very good + good” 100% vs 86.7%, P = 0.042), whereas patient satisfaction scores were comparable between the groups. En bloc resection was performed 100% of the time in both groups, and the complete resection rate was 94.4% in the DR group and 100% in the PR group (P = 0.477).

CONCLUSION: The efficacy and safety of dexmedetomidine and remifentanil were comparable to propofol and remifentanil during ESD. However, the endoscopists favored dexmedetomidine perhaps due to lower gastric motility.

Assessing the stability and safety of procedure during endoscopic submucosal dissection according to sedation methods: a randomized trial

BACKGROUND

Although endoscopic submucosal dissection (ESD) is routinely performed under sedation, the difference in ESD performance according to sedation method is not well known. This study attempted to prospectively assess and compare the satisfaction of the endoscopists and patient stability during ESD between two sedation methods.

METHODS

One hundred and fifty-four adult patients scheduled for ESD were sedated by either the IMIE (intermittent midazolam/propofol injection by endoscopist) or CPIA (continuous propofol infusion by anesthesiologist) method. The primary endpoint of this study was to compare the level of satisfaction of the endoscopists between the two groups. The secondary endpoints included level of satisfaction of the patients, patient's pain scores, events interfering with the procedure, incidence of unintended deep sedation, hemodynamic and respiratory events, and ESD outcomes and complications.

RESULTS

Level of satisfaction of the endoscopists was significantly higher in the CPIA Group compared to the IMIE group (IMIE vs. CPIA; high satisfaction score; 63.2% vs. 87.2%, P=0.001). The incidence of unintended deep sedation was significantly higher in the IMIE Group compared to the CPIA Group (IMIE vs. CPIA; 17.1% vs. 5.1%, P=0.018) as well as the number of patients showing spontaneous movement or those requiring physical restraint (IMIE vs. CPIA; spontaneous movement; 60.5% vs. 42.3%, P=0.024, physical restraint; 27.6% vs. 10.3%, P=0.006, respectively). In contrast, level of satisfaction of the patients were found to be significantly higher in the IMIE Group (IMIE vs. CPIA; high satisfaction score; 85.5% vs. 67.9%, P=0.027). Pain scores of the patients, hemodynamic and respiratory events, and ESD outcomes and complications were not different between the two groups.

CONCLUSION

Continuous propofol and remifentanil infusion by an anesthesiologist during ESD can increase the satisfaction levels of the endoscopists by providing a more stable state of sedation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01806753.

Two-surgeon technique for liver transection using precoagulation by a soft-coagulation system and ultrasonic dissection

BACKGROUND/AIMS

A soft-coagulation system (SCS) was introduced as an effective device to reduce blood loss in hepatectomy. Here we evaluated the efficacy of a two-surgeon technique using precoagulation by an SCS and the Cavitron Ultrasonic Surgical Aspirator (CUSA) for liver transection.

METHODOLOGY

The 163 patients with liver tumors were divided into two groups (conventional group and two-surgeon group). Liver transection was conducted using saline-coupled bipolar electrocautery and CUSA in 102 patients (conventional group). In 61 patients (the two-surgeon group), a two-surgeon technique using precoagulation by an SCS and CUSA for liver resection was performed.

RESULTS

The median blood loss was significantly less in the two-surgeon group compared to the conventional group (354.8 mL vs. 557.8 mL, respec tively: p = 0.0011). The postoperative hospital stay was significantly shorter in the two-surgeon group compared to the conventional group (12.7 days vs. 15.5 days, p = 0.0035).

CONCLUSIONS

The two-surgeon technique using precoagulation by an SCS and CUSA was significantly reduced blood loss during liver transection, and associated with low morbidity and mortality. This technique may be useful for many hepatobiliary surgeons.

A single-center experience of endoscopic submucosal dissection performed in a Western setting

BACKGROUND

Compared with the piecemeal resection associated with endoscopic mucosal resection, endoscopic submucosal dissection (ESD) enables en bloc resection of larger lesions, allows for more accurate histological assessments, and has reduced recurrence rates. ESD is not widely performed in Western countries given increased technical difficulty, high complication rates, and long procedure times.

AIMS

To evaluate the safety and efficacy of ESD in a single center in the USA.

METHODS

A retrospective study on a prospectively collected database identified cases in which a single operator (IW) performed ESD at a tertiary referral center. Twenty cases were identified, nine in the upper digestive tract (four esophagus and five stomach) and 11 in the lower digestive tract (nine rectal and two sigmoid colon). Data regarding lesion location, pathology, method of ESD (composition/volume of lifting injection and resection method), post-procedure complications, and margin involvement were collected.

RESULTS

En bloc resection was obtained in 14/20 patients (70 %). The average procedure time was 202 min in the esophagus, 148 min in the stomach, and 106 min for lower lesions. A major complication (perforation) occurred in 1/20 cases (5 %). Complete resection was obtained in 14/20 (70 %). R0 resection was obtained in 16/20 (80 %) cases.

CONCLUSIONS

The complication, en bloc resection, and complete resection rates of this study are similar to those found in large studies on ESD performed in Eastern settings. ESD is safe and efficacious for en bloc resections of pre-malignant and early-invasive lesions, and should be offered to patients with suitable lesions in Western settings.

A randomized controlled trial of endoscopic steroid injection for prophylaxis of esophageal stenoses after extensive endoscopic submucosal dissection

BACKGROUND

Esophageal stenosis following endoscopic submucosal dissection (ESD) is a serious adverse event that makes subsequent management more difficult.

METHODS

This parallel, randomized, controlled, open-label study was designed to examine whether local steroid injection is an effective prophylactic treatment for esophageal stenoses following extensive ESD. This single center trial was conducted at the Keiyukai Hospital, a tertiary care center for gastrointestinal disease in Japan [University Hospital Medical Network Clinical Trial Registry (UMIN-CTR) on 15 September 2011 (UMIN000006327)]. Thirty-two patients with mucosal defects involving ≥75% of the esophageal circumference were randomized to receive a single dose of triamcinolone acetonide injections (n = 16) or be treated conventionally (n = 16). The primary outcome was the frequency of stricture requiring endoscopic dilatation; the surrogate primary endpoint was the number of dilatation sessions needed. Secondary outcomes included adverse event rates, the minimum diameter of the stenotic area and the duration of the course of dilatation treatments.

RESULTS

The frequency of stricture was not significantly different between the groups because of insufficient statistical power, but the number of dilatation sessions required was significantly less in the steroid group (6.1 sessions [95% confidence interval, CI 2.8-9.4] versus 12.5 [95% CI 7.1-17.9] sessions in the control group; P = 0.04). The perforation rate was similar in both groups. The minimum diameter of stenotic lumens was significantly greater in the treatment group than controls (11.0 mm versus 7.1 mm, respectively; P = 0.01). The perforation rate was not significantly different between the groups (1.0% versus 0.5% in the treatment and control group, respectively). Steroid injection was effective in cases of mucosal defects encompassing the entire esophageal circumference.

CONCLUSIONS

Prophylactic endoscopic steroid injection appears to be a safe means of relieving the severity of esophageal stenoses following extensive ESD.

Clinical characteristics and management of gastric tube cancer with endoscopic submucosal dissection

AIM: To identify the characteristics of gastric tube cancer (GTC) and the complications associated with endoscopic submucosal dissection (ESD) for GTC.

METHODS: Between 2007 and 2012, 11 individuals with early gastric cancer in the reconstructed gastric tube after esophagectomy who underwent ESD in this hospital were studied. The characteristics of GTC were identified, and the complications of ESD for GTC were analyzed at three phases: preoperative, intraoperative, and postoperative.

RESULTS: A total of 11 consecutive patients with 11 GTCs were selected for this study. All cases underwent en bloc resections by ESD. The median procedure time was 142 min. The average GTC diameter was 26.1 mm, and the average size of the resected lesions was 45.5 mm. The histopathological diagnosis in all cases was a differentiated adenocarcinoma. In the preoperative phase, anastomotic strictures (5/11, 45%) and food residues (4/11, 36.4%) in the gastric tube were the main complications. In the intraoperative phase, bleeding was observed in 5 cases (45%). The postoperative complications observed were delayed bleeding in 2 cases (18.2%) and stenosis in one case (9.1%). The case with stenosis was successfully treated using endoscopic balloon dilatation.

CONCLUSION: Minor complications were frequently observed. However, all GTCs underwent en bloc resection with ESD without any serious complications. ESD is considered a useful treatment for GTC.

High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients

BACKGROUND

Few facelift methods are designed specifically for Asian patients. Because of their characteristic thick skin and flat, wide facial geometry, satisfactory facelift results can be difficult to achieve in these patients.

OBJECTIVES

The authors evaluated outcomes achieved with a high superficial musculoaponeurotic system (high-SMAS) facelift with finger-assisted facial spaces dissection to rejuvenate the aging Asian face.

METHODS

Fifty-three patients underwent this facelift procedure. The indication for surgery was typical sagging of the face associated with aging; the relative contraindications were previous facelift and severe facial atrophy.

RESULTS

Mean patient age was 50.7 years. Patients received follow-up for a mean of 19 months. In all cases, improvement was seen in soft-tissue sagging of the midface and lower face. One patient experienced unilateral temporal nerve injury, 3 experienced hematoma, and 2 had wound dehiscence.

CONCLUSIONS

Understanding surgical anatomy including facial layers, spaces, and retaining ligaments is crucial for stable application of facelift techniques in Asian patients. Because of the small number of patients evaluated in this study and the limited follow-up period, more research is needed to define suitable facelift methods for these patients.

Perioperative complications of endoscopic submucosal dissection for early gastric cancer in elderly Japanese patients 75 years of age or older

OBJECTIVE

The number of endoscopic submucosal dissection (ESD) procedures for early gastric cancers among patients 75 years of age or older has been increasing. We herein examined both the outcomes and complications of ESD in elderly patients.

METHODS

We investigated the effects of underlying diseases, lesion characteristics, treatment outcomes and complications during and in the postoperative periods of ESD among elderly patients 75 years of age or older versus non-elderly patients less than 75 years of age. Patients A total of 318 early gastric cancers in consecutive 307 patients, all of whom underwent ESD for gastric cancer, were included in this study.

RESULTS

The number of patients with hypertension and ischemic heart disease was significantly higher in the elderly group than in the non-elderly group. The proportion of lesions with an absolute indication, extended indication or no indication was not significantly different between the groups. During the ESD procedure, the use of atropine sulfate for bradycardia was significantly more frequent in the elderly group. No significant differences were observed between the groups in terms of the treatment for hypertension, oxygen administration or incidence of perforation. In addition, there were no significant differences with respect to oxygen administration, postoperative bleeding or the occurrence of fever and/or pneumonia after the ESD procedure.

CONCLUSION

Although bradycardia was more frequently observed in the elderly patients during ESD in this study, ESD was performed safely and managed appropriately, with infrequent postoperative complications. ESD appears to be effective, even in elderly patients.

Efficacy and safety of endoscopic resection therapies for rectal carcinoid tumors: a meta-analysis

PURPOSE

Several endoscopic resection therapies have been applied for the treatment of rectal carcinoid tumors. However, there is currently no consensus regarding the optimal strategy. We performed a meta-analysis to compare the efficacy and safety of endoscopic mucosal resection (EMR) or modified EMR (m-EMR) versus endoscopic submucosal dissection (ESD) for the treatment of rectal carcinoid tumors.

MATERIALS AND METHODS

PubMed, Web of Science, Medline, Embase and CNKI were searched up to the end of January 2014 in order to identify all studies on the effects of EMR (or m-EMR) and ESD on rectal carcinoid tumors.

RESULTS

A total of fourteen studies involving 782 patients were included. The pooled data suggested a significantly higher rate of pathological complete resection among patients treated with ESD or m-EMR than those treated with EMR [odds ratio (OR)=0.42, 95% confidence interval (CI): 0.25-0.71; OR=0.10, 95% CI: 0.03-0.33, respectively], while there was no significant difference between the m-EMR group and ESD group (OR=1.19, 95% CI: 0.49-2.86); The procedure time of ESD was longer than EMR or m-EMR groups [mean differences (MD)=-11.29, 95% CI: -14.19 - -8.38, MD= -10.90, 95% CI: -18.69 - -3.11, respectively], but it was insignificance between the EMR and m-EMR groups. No significant differences were detected among the treatment groups with regard to complications or recurrence.

CONCLUSION

The results of this meta-analysis suggest that treatment of rectal carcinoid tumors with ESD or m-EMR is superior to EMR, and the efficacy of m-EMR is equivalence to ESD treatment. However, more well-designed studies are needed to confirm these findings.

The effect of short-term proton pump inhibitor plus anti-ulcer drug on the healing of endoscopic submucosal dissection-derived artificial ulcer: a randomized controlled trial

BACKGROUND/AIMS

Artificial ulcers remain a major complication after Endoscopic submucosal dissection (ESD). The development of more effective treatment regimen for this ulcer is required than the use of proton pump inhibitor (PPI) alone.

METHODOLOGY

Patients with ESD-derived artificial ulcers were randomly assigned to two groups: a group of patients who received rabeprazole 20 mg daily for 8 weeks (PPI group) and a group of patients who received a combination of rebamipide 300 mg daily for 8 weeks and rabeprazole 20 mg dairy for the first 4 weeks (reb+PPI group). The area reduction ratio and healing status of ulcers were evaluated endoscopically on postoperative 7, 28 and 56 days.

RESULTS

The overall ulcer area reduction ratio was higher in the reb+PPI group than in the PPI group, especially at an early stage. The ratio of progression to the H1 stage in the reb+PPI group was significantly higher than that in the PPI group, especially at an early stage.

CONCLUSIONS

Treatment with 8 weeks of rebamipide plus the first 4 weeks of PPI demonstrated a reduction ratio of artificial ulcers superior to that with 8 weeks of PPI mono-therapy. This combination treatment is, therefore, one of the candidate treatment strategies against ESD-derived artificial ulcers.

Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms

BACKGROUND AND OBJECTIVES

There are several published studies examining the major complications (bleeding and perforation) of colon endoscopic submucosal dissection (ESD). However, little is known about the other complications, such as post-ESD coagulation syndrome (CS). The aims of this study were to evaluate the prevalence and the clinical features of CS after colon ESD.

METHODS

There were 183 cases treated with ESD for either a colorectal laterally spreading tumor or a polypoid mass in Konkuk University Medical Center. There were 151 cases enrolled in this study after excluding patients with perforation, bleeding, nonlifting sign, or nonneoplastic lesions. Patients with a fever above 37.7 °C, abdominal pain, and localized tenderness after ESD without macro- or microperforation, regardless of the symptoms of peritoneal irritation, were deemed as showing post-colon ESD CS.

RESULTS

There were 151 cases enrolled in this study, and 13 patients (8.6 %) showed CS after colorectal ESD. There were no differences in the demographic and endoscopic characteristics between the patients with CS and those without CS. The mean hospitalization stay was 3.0 ± 0.3 days longer in the CS (+) group (6.9 ± 1.9 days) than that in the CS (-) group (3.9 ± 1.6 days) (p = 0.001). All patients with CS were treated with conservative, nonsurgical management, such as fasting and intravenous antibiotics.

CONCLUSIONS

The rate of post-ESD CS was less than 9 % in this study. Although CS occurred, all of the patients with CS showed a favorable progression within 1 week.

Two-week treatment with proton pump inhibitor is sufficient for healing post endoscopic submucosal dissection ulcers

AIM: To investigate the optimum period of treatment for post endoscopic submucosal dissection (ESD) ulcers.

METHODS: Patients who underwent ESD for gastric cancer were randomized to two groups and treated with esomeprazole 20 mg per day for 4 wk (4W group) or 2 wk (2W group). At 4 wk after ESD, we measured the size of the artificial ulcers by endoscopy and determined the ulcer healing rate, compared with the size of the ESD specimens. This randomized controlled trial study was approved by our ethics committee and registered in the UMIN Clinical Trial Registry.

RESULTS: A total of 60 consecutive patients were included in the study. All patients received rebamipide 300 mg per day for 4 wk. One patient in 2W group who showed bleeding within two weeks and received endoscopic treatment was excluded from further analysis. The numbers of patients with ulcers in the healing/scar stage in the 2W and 4W groups at 4 wk after ESD were 20/6 and 28/5, respectively, with no significant difference. The ulcer healing rate in the 2W and 4W groups were 96.1% [95% confidence interval (CI): 94.6%-97.55] vs 94.8% (95%CI: 92.6%-97.1%), respectively, with no statistical difference (UMIN000006951).

CONCLUSION: Two-wk treatment with a proton pump inhibitor is as effective as four-week treatment for healing post ESD ulcers.

Prevention of esophageal strictures after endoscopic submucosal dissection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have recently been accepted as less invasive methods for treating patients with early esophageal cancers such as squamous cell carcinoma and dysplasia of Barrett’s esophagus. However, the large defects in the esophageal mucosa often cause severe esophageal strictures, which dramatically reduce the patient’s quality of life. Although preventive endoscopic balloon dilatation can reduce dysphagia and the frequency of dilatation, other approaches are necessary to prevent esophageal strictures after ESD. This review describes several strategies for preventing esophageal strictures after ESD, with a particular focus on anti-inflammatory and tissue engineering approaches. The local injection of triamcinolone acetonide and other systemic steroid therapies are frequently used to prevent esophageal strictures after ESD. Tissue engineering approaches for preventing esophageal strictures have recently been applied in basic research studies. Scaffolds with temporary stents have been applied in five cases, and this technique has been shown to be safe and is anticipated to prevent esophageal strictures. Fabricated autologous oral mucosal epithelial cell sheets to cover the defective mucosa similarly to how commercially available skin products fabricated from epidermal cells are used for skin defects or in cases of intractable ulcers. Fabricated autologous oral-mucosal-epithelial cell sheets have already been shown to be safe.

Combination therapy for perianal squamous cell carcinoma in situ with imiquimod and photodynamic therapy

Perianal squamous cell carcinoma in situ (SCCIS) is a relatively rare intraepidermal neoplasm that has the potential to progress to invasive squamous cell carcinoma. First-line treatment is surgical excision, though nonsurgical treatment modalities such as 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT) and imiquimod also have been investigated for this neoplasm. Unfortunately, recurrences are known to occur after both surgical and nonsurgical monotherapies. We report a case of perianal SCCIS that was successfully treated with a novel combination of ALA-PDT and imiquimod.