Endoscopic Management of Ampullary Adenomas in Familial Adenomatous Polyposis Syndrome: A Systematic Review with Pooled Analysis

BACKGROUND

Endoscopic papillectomy is a viable therapy in ampullary lesions. Prior studies have reported on outcomes of sporadic ampullary lesions, and only small cohort studies have reported outcomes associated with familial adenomatous polyposis (FAP) syndrome.

AIMS

We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for treating ampullary adenomas in FAP.

METHODS

We performed a comprehensive literature search of major databases from inception to May 2020. Studies that included patients with endoscopically resected ampullary lesions and FAP were eligible. The rate of technical success, en bloc resection, piecemeal resection, recurrence, and adverse events was pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval (CI).

RESULTS

Six studies, including a total of 99 patients, were included in our final analysis. Patient age ranged from 28 to 91 years. Pooled technical success was 90.3% (CI 76.9-96.3%, I² = 31%). Rate of en bloc resection was 60.6% (CI 47.9-72.0%, I² = 0%). Recurrence rate was 25.4% (5.7-65.9%, I² = 82%). The post-procedural pancreatitis rate was 14.7% of which 68% (51 of 75) utilized prophylactic pancreatic stenting. Other adverse events included bleeding (9.2%) and perforation (4%).

CONCLUSION

Endoscopic papillectomy offers high technical success but remains challenging in patients with FAP, particularly due to high recurrence rates.

Comparison of effectiveness and safety between endoscopic and surgical resection for 2-5 cm gastric stromal tumors

BACKGROUND

As endoscopic resection remains controversial, this study aims to compare the effectiveness and safety between endoscopic and surgical resection for 2-5 cm gastric stromal tumors (GSTs).

METHODS

Patients with 2-5 cm GST resected at West China Hospital from March 2008 to April 2019 were enrolled. Propensity score matching (PSM) (1:1) was performed to achieve baseline data consistency.

RESULTS

112 patients were matched between the endoscopic resection group (ER) and the open surgery group. There were no significant differences in the complete resection rate (94.6% vs. 100%), the incidence of complications (25.0% vs. 14.3%), the recurrence rate (0% vs. 1.8%) and the 5-year relapse-free survival (100% vs. 97.9%) (P > 0.05). The ER had a shorter fasting time (3.5 days vs. 5 days), a shorter postoperative hospital stay (7 days vs. 8 days) and a lower hospitalization cost (3,589.16 USD vs. 5,931.24 USD) (P < 0.05). 54 cases were matched between the ER and the laparoscopic surgery group (LS). There were no significant differences in the complete resection rate (92.6% vs. 96.3%), the incidence of complications (22.2% vs. 11.1%), the fasting time (4 days vs. 3 days), the recurrence rate (0% vs. 3.7%) and the 5-year relapse-free survival (100% vs. 96.3%) (P > 0.05). The hospitalization cost (3,589.25 USD vs. 4,715.16 USD) was lower in the ER, and the postoperative hospital stay was shorter in the LS (6 days vs. 7 days) (P < 0.05).

CONCLUSIONS

Although slightly higher incidences of incomplete resection and perforation were shown in the endoscopic resection group, there was insignificant difference between groups (P > 0.05). Endoscopic resection might be an alternative surgical method for 2-5 cm GSTs.

Primary gastric dedifferentiated liposarcoma resected endoscopically: A case report

BACKGROUND

Liposarcoma is one of the most common adult mesenchymal tumors but is uncommon in the gastrointestinal tract and extremely rare in the stomach. Furthermore, the histological subtypes of liposarcoma usually reported in the stomach are well-differentiated or myxoid, and few reports have been issued on small-sized gastric liposarcomas resected endoscopically and followed up. Herein, we report a case of primary gastric dedifferentiated liposarcoma (DL) that was resected endoscopically.

CASE SUMMARY

A 67-year-old female Korean patient was referred to our institution for further evaluation of a gastric submucosal tumor (SMT) located in the lesser curvature of the gastric body by esophagogastroduodenoscopy. Endoscopic ultrasound revealed a well-circumscribed, slightly heterogeneous, isoechoic, 17 mm × 10 mm sized mass originating from the third sonographic layer. Computed tomography showed no evidence of significant lymph node enlargement or distant metastasis. Endoscopic resection was undertaken using the snare resection technique after mucosal precutting to provide a definitive histopathologic diagnosis, which proved to be consistent with DL, based on its morphology and the immunoexpressions of MDM2 and CDK4. The patient was planned for surgery because the deep resection margin was positive for malignancy. After declining any invasive procedure or adjuvant treatment, the patient was placed under close follow-up, and at one year after endoscopic resection, remained disease free.

CONCLUSION

This is the first reported case of a small primary gastric DL resected endoscopically and followed up. This report demonstrates that when diagnosis of a SMT is uncertain, the use of invasive techniques, including endoscopic resection, should be considered.

Long-term prognosis of small gastric gastrointestinal stromal tumors with high histological grade: a longitudinal nested cohort study

BACKGROUND AND AIMS

Gastrointestinal stromal tumors (GIST) are mostly seen in the stomach. Clinical data on GISTs ≤ 2 cm with > 5 mitosis/50 HPFs are limited. This study aimed to analyze small GISTs with high histological grades to gain a more comprehensive understanding of their clinical characteristics with long-term follow-up.

METHODS

This was a nested cohort study of patients with gastric GISTs ≤ 2 cm and > 5 mitosis/50 HPFs. Individuals with endoscopically resected gastric specimens diagnosed as GISTs between January 2008 and July 2019 were enrolled. We analyzed baseline clinicopathological characteristics, perioperative characteristics, risk of recurrence, and metastasis during follow-up.

RESULTS

A total of 55 patients diagnosed with gastric GISTs ≤ 2 cm and > 5 mitosis/50 HPFs were enrolled. The mean tumor size was 1.6 ± 0.4 cm (median 1.7 cm, range 0.8-2.0 cm). ESD was performed in 33 patients (60.0%) and EFTR in 22 patients (40.0%). Mean mitotic figures were 8.9/50 HPFs. Postoperative bleeding in one patient (1.8%) was the only severe adverse event. The mean follow-up period was 61.2 ± 33.9 months (median 53 months, range 13-133 months). Five patients (5/55, 9.1%) received additional therapies, including partial gastrectomy and adjuvant Imatinib. Only two patients (2/55, 3.6%) showed signs of recurrence. We observed no significant difference regarding baseline clinical characteristics and recurrence among GISTs with mitosis < 10/50 HPF and ≥ 10/50 HPF. No patient had signs of metastasis during follow-up.

CONCLUSION

Endoscopic resection of gastric GISTs ≤ 2 cm with > 5 mitosis/50 HPFs has a low risk of recurrence and metastasis in the long term. Endoscopic resection of GISTs is safe and feasible.

Safety and efficacy of surgical and endoscopic resection in the treatment of duodenal subepithelial lesions

BACKGROUND

Duodenal subepithelial lesions (D-SELs) are rare and their resection is challenging. Unfortunately, data on surgical and endoscopic resection of D-SELs are scarce. This study aimed to assess the safety and efficacy of surgical resection and endoscopic resection (ER) for D-SELs.

METHODS

We retrospectively analyzed clinical data of patients with non-ampullary D-SELs who underwent ER or surgery and compared the outcomes between ER and surgery with no/low-risk SELs over 15 mm from March 2010 to August 2020. Clinicopathologic findings, procedure-related parameters, and follow-up data were analyzed.

RESULTS

A total of 107 patients (108 lesions) were enrolled; 52 patients (53 lesions) received ER and 55 patients (55 lesions) received surgery. In ER group, en bloc resection rate and R0 resection rate were 94 and 89%, respectively. Major adverse events rate was 6%. One (2%) patient experienced local recurrence. In surgery group, R0 resection was achieved in all cases. Major adverse events rate was 20%. Recurrence rate and distant metastases rate were 4 and 8%, respectively. One (2%) patient died from septicemia during follow-up. Thirty-three patients in each group were enrolled in the comparison. There were no significant differences in age, sex, lesion size and location (P > 0.05). More histologically GISTs and muscularis propria-originated lesions were treated by surgery (P < 0.05). ER was significantly associated with a shorter operation time, shorter hospital stay, lower cost, less estimated blood loss, and lower major adverse events rate compared to the surgery group (P < 0.05). However, R0 resection rate, mortality, recurrence rate, and metastases rate were not significant different (P > 0.05).

CONCLUSIONS

ER is an effective and safe treatment modality for selected patients with non-ampullary D-SELs by expert endoscopists. Surgery is a radical method for D-SELs that should be reserved for D-SELs not amenable to ER.

Lymph node involvement in gastric adenocarcinoma

BACKGROUND

Endoscopic management of early gastric cancer is limited by the risk of lymph node metastasis. We aimed to examine the incidence and predictors of nodal metastasis in early gastric adenocarcinoma in a large national US cohort.

METHODS

Cases were abstracted from the National Cancer Database from 2004 to 2016. The incidence and predictors of lymph node involvement for patients with Tis, T1a, and T1b tumors were examined.

RESULTS

A total of 202,216 cases of gastric adenocarcinoma were identified in the NCDB. Cases with unknown patient or tumor characteristics, presence of other cancers, and prior neoadjuvant chemotherapy or radiotherapy were excluded. 1839 cases of Tis, T1a, and T1b tumors were identified. Lymph node metastases were present in 18.1% of patients. Lymphovascular invasion (LVI), high-grade histology, stage T1b, and larger size (> 3 cm) were independently associated with an increased risk of nodal metastasis on multivariate analysis (P < 0.05). The presence of LVI was the strongest predictor of nodal metastasis with an OR (95% CI) of 5.7 (4.3-7.6), P < 0.001. No lymph node metastasis was found in any Tis tumors. Small T1a low-grade tumors with no LVI had a low risk of nodal metastasis (0.6% < 2 cm and 0.9% < 3 cm).

CONCLUSION

In this large national cohort, size, lymphovascular invasion, higher grade histology, and T stage were independently associated with lymph node metastasis. For patients with low-grade tumors, < 3 cm, without lymphovascular invasion, the risk of nodal involvement was very low, suggesting that this Western cohort could be considered for endoscopic resection.

Correction to “Efficacy and safety of endoscopic resection in treatment of small gastric stromal tumors: A state-of-the-art review”

We corrected the name of our institution in this study. The correct name should be “"Department of Gastroenterology, The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen 518000, Guangdong Province, China".

A rare gastric lesion: diminutive, well-differentiated, Grade 3, type 3 gastric neuroendocrine tumor with extremely high ki-67 index removed en bloc under endoscopy

Grade 3, type 3 gastric neuroendocrine tumor (g-NET) shows specific features of clinical interest and the therapeutic management of the lesion is not yet completely standardized. We present the unusual case of a 34-year-old male patient with a diminutive (less than 0.5 cm), well-differentiated, G3, type 3g-NET with extremely high Ki-67 index (higher than 80%). The lesion was subsequently removed en bloc via endoscopic submucosal dissection. Regarding the proliferation rate, Ki-67 index values usually range from 21 to 50%, and less commonly above 55%, in G3 NET. To our knowledge, this lesion represents a small size with the highest Ki-67 index diagnosed with G3 g-NET. However, as g-NET might recur even after a long duration, we recommend a long-term follow-up, such as 10 years after complete resection in patients to evaluate the endoscopic resection approach.

Advanced Endoscopic Resection Techniques: Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection

Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.

Safety and efficacy of common endoscopic treatments in patients with decompensated liver cirrhosis

INTRODUCTION

The safety and efficacy have always been a concern, when patients with decompensated liver cirrhosis (DLC) receive endoscopic treatments.

METHODS

To evaluate the safety and efficacy of common endoscopic treatments including endoscopic resection (ER) and endoscopic retrograde cholangiopancreatography (ERCP) applying to patients with DLC, we performed a retrospective study finally including 81 patients receiving ER (43 endoscopic mucosal resection (EMR) and 38 endoscopic submucosal dissection (ESD)) and 131 patients treated by ERCP.

RESULTS

There were no significant differences in the rate of degeneration and invariability of Child-Pugh (CP) class and the overall rate of adverse events between two groups (93.8%/8.6% ER vs. 96.2%/15.3% ERCP). Both the degeneration rate of CP class (35.4%) and the rate of adverse events (27.1%) in subgroup CP class C of ERCP group were significantly higher (P=0). The rate of poor outcomes was higher in ERCP group (12.2%) than that in ER group (2.5%) (P=0.02). And subgroup CP class C of ERCP group had a higher poor outcome rate (27.1%) (P=0).

CONCLUSION

ER and ERCP could remove focal lesions or relieve symptoms induced by targeted diseases without significant changes of CP class. Significant benefits and risks coexisted in CP class C patients with DLC when receiving ERCP.

Endoscopic excision as a viable alternative to major resection for early duodenal cancers: A population-based cohort study

BACKGROUND

Duodenal cancer presents an elusive therapeutic challenge for clinicians to treat because of its highly malignant behavior and anatomical complexity. Endoscopic excision has been administered to treat early-stage cancers of upper gastrointestinal tract, especially esophagus and stomach cancer. There is currently a scarcity of data regarding the application and efficacy of endoscopic resection for early duodenal cancer due to its rarity. This study aimed at exploring the prevalence and efficacy of endoscopic excision in treatment for early duodenal cancer in comparison with major surgery.

METHODS

This cohort study retrospectively collected patients with primary Tis/T1-N0-M0 duodenal cancer in the Surveillance, Epidemiology, and End Results database from 2004 to 2017. Prevalence of endoscopic excision in duodenal cancer treatment, overall survival (OS) and disease-specific survival (DSS) of patients who received different tumor-resection procedures were estimated.

RESULTS

A total of 1354 patients with Tis/T1-stage duodenal cancer were identified. Most patients (69.4%) underwent tumor resection as initial treatments. Among them, 65.7% underwent endoscopic excision, while 34.3% underwent major surgery. The multivariable Cox analyses revealed that endoscopic excision was associated with a significantly favorable OS (HR: 0.70; 95% CI: 0.52-0.95, p = 0.02) and DSS (HR: 0.32; 95% CI: 0.17-0.60, p < 0.001), compared to major surgery, for Tis/T1-stage cancer patients. In addition to cancer-related deaths (p < 0.001), endoscopic resection manifested significantly lower cumulative mortality rate of post-operative infectious diseases (p = 0.03).

CONCLUSION

Endoscopic resection currently accounted for approximately two-thirds of all procedures to resect Tis/T1-stage duodenal tumor. Endoscopic resection represents a viable therapeutic option in the management of Tis/T1-stage duodenal cancer for its oncological superiorities to major surgery and its capacity to reduce operative traumas and morbidities.

Clinical outcomes of endoscopic resection of superficial nonampullary duodenal epithelial tumors: A 10-year retrospective, single-center study

BACKGROUND

Although premalignant duodenal lesions such as adenomas are uncommon, the incidences of these lesions have increased in recent times, and thus, the demand for minimally invasive treatments such as endoscopic resection (ER) has also increased. However, ER in the duodenum is more challenging than ER in other locations of the gastrointestinal tract.

AIM

To evaluate the safety and efficacy of ER for superficial nonampullary duodenal epithelial tumors (SNADETs)

METHODS

We performed a retrospective observational study on 56 consecutive patients (58 lesions) diagnosed with SNADETs that underwent ER from January 2011 to December 2020 at Yeungnam University Hospital. Patient demographics, lesion characteristics, and procedural and technical data were collected, and clinical outcomes, including procedure-related complications, completeness of resection, and recurrence were analyzed.

RESULTS

Median patient age was 57 years [range, 26–77, 30 (53.6%) men]. Endoscopic mucosal resection (EMR) was performed on 57 lesions (98.3%) and snare polypectomy on one (1.7%). Lesions consisted of 52 adenomas with low-grade dysplasia (89.7%), 3 adenomas with high-grade dysplasia (5.2%), and 3 intramucosal adenocarcinomas (5.2%). There were 16 cases of intraprocedural bleeding (27.6%) and 1 case of delayed bleeding (1.7%), and all these 17 cases were successfully managed endoscopically. No perforation or procedure-related death occurred. Larger lesion size was associated with an increased risk of EMR-related bleeding (P = 0.033). During a median follow-up period of 23 mo (range 6–100 mo), no local recurrence occurred, despite the fact one-third of the patients (19 lesions, 32.8%) underwent piecemeal resection and 3 patients (3 lesions, 5.2%) that underwent en bloc resection had a pathologically determined positive lateral margin. No patient died from a primary duodenal neoplasm.

CONCLUSION

The majority of SNADETs can be safely and curatively resected by EMR, and thus, based on consideration of the high incidence of fatal complications attributable to ESD, we conclude EMR, including piecemeal resection, should be considered the treatment of first choice for SNADETs.

Colon Polypectomy with Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection

Endoscopic resection has become the gold standard for the management of most of the large colorectal polyps. Various endoscopic resection techniques include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). ESD is a minimally invasive method for the resection of advanced lesions in the gastrointestinal (GI) tract to achieve en-bloc resection. While, EFTR is more commonly used in lesions with suspected deeper submucosal invasion, lesions originating from muscularis propria, or those with advanced fibrosis. This article reviews the indications, technique, and adverse events for use of ESD and EFTR in the colon.

The usefulness of combining the pocket-creation method with a traction device using a scissor-type knife for colorectal endoscopic submucosal dissection

INTRODUCTION

Technical issues and long procedure time still remain a concern in colorectal endoscopic submucosal dissection (ESD). We examined the usefulness of combining the pocket-creation method (PCM) with a traction device (S-O clip; SO) using a scissor-type knife (Clutch Cutter 3.5 mm; CC) for decreasing ESD procedure time.

METHODS

We retrospectively analyzed 95 ESD cases of PCM + SO + CC managed from August 2017 to April 2020 and 103 cases of PCM + CC treated from July 2016 to July 2017. We compared these two groups through propensity score matching. The main outcome was the analysis of the ESD procedure times under various conditions in each group.

RESULTS

After matching, 52 cases in the PCM + SO + CC and PCM + CC groups were analyzed. The PCM + SO + CC group showed a significantly shorter ESD procedure time than the PCM + CC group (57.8 ± 31.4 vs. 81.7 ± 33.5 min, p < 0.01). Additionally, the ESD procedure time was significantly shorter in the PCM + SO + CC group than in the PCM + CC group: tumor size (tumor size < 40 mm: 45.6 ± 15.8 vs. 72.7 ± 22.9 min, p < 0.01; tumor size ≥ 40 mm: 83.1 ± 40.1 vs. 111.8 ± 45.3 min, p = 0.04), tumor location (right side: 64.7 ± 33.3 vs. 81.0 ± 29.7 min, p = 0.03; left side: 50.5 ± 28.0 vs. 82.3 ± 36.9 min, p < 0.01), tumor morphology (polypoid: 39.2 ± 18.6 vs. 74.7 ± 28.6 min, p < 0.01; nonpolypoid: 62.3 ± 32.3 vs. 84.5 ± 35.2 min, p < 0.01), endoscopist (expert: 67.3 ± 41.2 vs. 91.9 ± 40.2 min, p = 0.02; nonexpert: 50.4 ± 18.3 vs. 73.6 ± 24.9 min, p < 0.01), and fibrosis (severe fibrosis: 82.0 ± 20.5 vs. 99.8 ± 40.4 min, p = 0.169; non-severe fibrosis: 52.1 ± 23.8 vs. 75.6 ± 29.0 min, p < 0.01).

CONCLUSIONS

The combination of the PCM and SO using CC achieved a reduction in the colorectal ESD procedure time.

Evolving roles of magnifying endoscopy and endoscopic resection for neoplasia in inflammatory bowel diseases

Magnifying endoscopy is a useful technique to differentiate neoplasia from non-neoplastic lesions. Data regarding the clinical utility of magnifying endoscopy for neoplasia in patients with inflammatory bowel disease (IBD) has been emerging. While Kudo’s pit pattern types III-V are findings suggestive of neoplasia in non-IBD patients, these pit patterns are predictive of IBD-associated neoplasia as well. However, active chronic inflammatory processes, particularly regenerative changes, can mimic neoplastic pit patterns and may affect a meticulous evaluation of pit pattern diagnosis in patients with IBD. The clinical evidence regarding the utility of magnifying endoscopy with narrow band imaging or endocytoscopy has also been evolving in regard to the diagnosis of IBD-associated neoplasia. These advanced endoscopic techniques are promising for multiple reasons; not only for making an accurate diagnosis of neoplasia, but also in determining if endoscopic resection is appropriate for such lesions in patients with IBD. In this review, we discuss the diagnostic accuracy and limitations of magnifying endoscopy in assessing IBD-associated neoplasia and examine the feasibility and outcomes of endoscopic resection for these lesions.

Feasibility Study of Partial Submucosal Injection Technique Combining Underwater EMR for Superficial Duodenal Epithelial Tumors

BACKGROUND AND AIMS

Endoscopic mucosal resection (EMR) and Underwater EMR have been reported as effective endoscopic treatment for superficial duodenal tumor (SDET). However, a notable problem of EMR for SDET is technical difficulty for the lesion with non-lifting sign, and it of UEMR is that en bloc resection rate is relatively low. Therefore, we performed partial submucosal injection combining UEMR (PI-UEMR). The aim of this study is to evaluate feasibility and safety of this technique for duodenal tumor.

METHODS

This is a prospective observational study from tertiary care hospital. We performed PI-UEMR in patients with SDET that is 13-20 mm in diameter, or less than 13 mm with technical difficulty for EMR and UEMR from January 2019 to March 2020. Primary outcome was en bloc resection rate. Secondary outcomes were R0 resection rate, mean total procedure time, intra- and post-procedure complication.

RESULTS

Thirty patients were included in this study. Mean age was 62 ± 12 years old. Three fourths lesions were located at anal side from major papilla. Median lesion size was 12 mm [IQR 10-16 mm]. Twenty-four cases were taken endoscopic biopsy in prior hospital and observed biopsy scar. En bloc resection rate was 97%. Ro resection rate was 83%. Mean total procedure time was 17 ± 12 min. And there was an only one case of complication, intra-procedure bleeding that was controllable endoscopically.

CONCLUSIONS

PI-UEMR might be very useful and safe technique of endoscopic resection for SDET including relatively large lesions.

Early gastric cancer: A challenge in Western countries

Early gastric cancer (EGC) is an invasive carcinoma involving only the stomach mucosa or submucosa, independently of lymph node status. EGC represents over 50% of cases in Japan and in South Korea, whereas it accounts only for approximately 20% of all newly diagnosed gastric cancers in Western countries. The main classification systems of EGC are the Vienna histopathologic classification and the Paris endoscopic classification of polypoid and non-polypoid lesions. A careful endoscopic assessment is fundamental to establish the best treatment of EGC. Generally, EGCs are curable if the lesion is completely removed by endoscopic resection or surgery. Some types of EGC can be resected endoscopically; for others the most appropriate treatment is surgical resection and D2 lymphadenectomy, especially in Western countries. The favorable oncological prognosis, the extended lymphadenectomy and the reconstruction of the intestinal continuity that excludes the duodenum make the prophylactic cholecystectomy mandatory to avoid the onset of biliary complications.

Prevention of late complications of endoscopic resection of colorectal lesions with a coverage agent: Current status of gastrointestinal endoscopy

Endoscopic ectomy of large nonpedunculated colorectal lesions (≥ 20 mm) might cause significant adverse incidents, such as delayed perforation and delayed bleeding, despite the closure of mucosal lesions with clips. The conventional utilization of prophylactic clipping has not decreased the risk of postprocedural delayed adverse events, and additional outcomes and cost-effectiveness research is needed for patients with proximal lesions ≥ 20 mm, in whom prophylactic clipping might be useful. Coverage of the wound after endoscopic excision offers shield protection against delayed concomitant diseases.

Feasibility of endoscopic resection for large pedunculated duodenal lesions (with video)

BACKGROUND

A standard treatment method for pedunculated duodenal lesions has not yet been established. This study aimed to evaluate the feasibility of endoscopic resection (ER) for pedunculated duodenal lesions, especially for large lesions.

METHODS

This study retrospectively reviewed cases of pedunculated duodenal lesions treated with ER at our institute between July 2010 and January 2021. We collected data on the clinical characteristics and treatment outcomes. In addition, the cases were divided based on the treatment provided for the lesion, i.e., the ESD and snare resection groups, and we compared the data between the two groups.

RESULTS

Thirty-eight cases were included in this study. The overall en bloc resection rate was 95%. No perforation occurred in any of the cases. There were 10 cases treated with ESD, which were considered difficult to achieve en bloc resection using snare forceps, and 28 cases treated with snare resection. Although the median lesion size was significantly larger in the ESD group than in the snare resection group (27 [range 23-66] vs. 19 [range 6-55] mm, P = 0.0052), treatment outcomes were not significantly different between the two groups. Among the 10 cases treated using ESD, en bloc resection was achieved in all cases, along with specimen retrieval without any perforations, despite the large size of the lesions.

CONCLUSION

ER could be performed to achieve a high en bloc resection rate without any perforations in pedunculated duodenal lesions, even in extremely large (e.g., ≧ 60 mm) lesions, suggesting that ER is feasible and may be an alternative to surgical resection for large pedunculated duodenal lesions.

Curative resection with endoscopic submucosal dissection of early gastric cancer in Helicobacter pylori-negative Ménétrier’s disease: A case report

BACKGROUND

Adult-onset Ménétrier’s disease is strongly associated with Helicobacter pylori (H. pylori) infection and an elevated risk of carcinogenesis. Cases of early-stage gastric cancer developed in H. pylori-negative Ménétrier’s disease are extremely rare. We report a case of early gastric cancer in H. pylori-negative Ménétrier’s disease that was curatively resected with endoscopic submucosal dissection (ESD).

CASE SUMMARY

A 60-year-old woman was referred to our hospital after her medical examination detected anemia. Contrast-enhanced upper gastrointestinal (UGI) radiography revealed translucency of the nodule-aggregating surface with giant rugae. Blood tests showed hypoproteinemia and were negative for serum H. pylori immunoglobulin G antibodies. The ^99mTc-DTPA-human serum albumin scintigraphy showed protein loss from the stomach. UGI endoscopy showed a 40-mm protruding erythematous lesion on giant rugae of the greater curvature of lower gastric body, suggesting early-stage gastric cancer due to Ménétrier’s disease. En bloc resection with ESD was performed for diagnosis and treatment. Histology of ESD showed well-differentiated tubular adenocarcinoma. The cancer was confined to the mucosa, and complete curative resection was achieved. Foveolar hyperplasia and atrophy of the gastric glands were observed in non-tumor areas, histologically corresponding to Ménétrier’s disease. Three years after ESD, gastric cancer had not recurred, and Ménétrier’s disease remained in remission with spontaneous regression of giant gastric rugae.

CONCLUSION

Complete curative resection was achieved through ESD in a patient with early-stage gastric cancer and H. pylori-negative Ménétrier’s disease.

Endoscopic resection versus esophagectomy for early esophageal cancer: a meta-analysis

Background

Esophagectomy is the standard treatment for early-stage esophageal cancer but is associated with high morbidity and mortality. Thus, endoscopic resection is increasingly used as an alternative option. However, the literature is inconsistent regarding the efficacy of these treatments. This meta-analysis aimed to compare the efficacy and safety of these two treatments.

Methods

A systematic electronic search of PubMed, EMBASE, and the Cochrane Library was performed for studies comparing endoscopic resection and surgery for early-stage esophageal cancer. The overall survival, tumor recurrence, major adverse events, procedure-related mortality, and R0 resection rates were investigated. Forest plots were constructed based on the random-effects model.

Results

We found 15 studies involving 2,467 and 2,264 patients who underwent endoscopic resection and surgery, respectively. The meta-analysis showed that patients undergoing endoscopic resection had significantly fewer major adverse events (relative risk, 0.46; 95% confidence interval, 0.33–0.64) and a lower procedure-related mortality rate (relative risk, 0.27; 95% confidence interval, 0.10–0.73) than those undergoing surgery. The number of postprocedural stricture events did not significantly differ between the two treatments (relative risk, 0.89; 95% confidence interval, 0.53–1.49). Endoscopic resection was associated with higher recurrence rates (relative risk, 1.69; 95% confidence interval, 0.99–2.89) and lower R0 resection rates (relative risk, 0.92; 95% confidence interval, 0.86–0.98) than surgery. There may be some advantage conferred by esophagectomy in the long-term survival outcomes (hazard ratio, 1.21; 95% confidence interval, 1.02–1.43).

Discussion

Endoscopic resection is a minimally invasive and safe treatment for early-stage esophageal cancer. However, esophagectomy may be associated with better long-term survival.

Sino-nasal hemangiopericytoma: a case series and systematic literature review

BACKGROUND

Hemangiopericytoma is a rare tumor of the sino-nasal tract. Its clinical behavior is controversial. Whereas some describe an indolent course, others consider it to be an aggressive lesion with a tendency toward rapid local recurrence. Here, we describe our experience in the management of sino-nasal hemangiopericytoma (SN-HPC), comparing our experience with the current literature, and evaluating signs and tools to improve diagnosis and treatment.

METHODS

All cases of SN-HPC between 2010 and 2020 were extracted and reviewed from our institutional electronic medical records. SN-HPC cases from PubMed and EMBASE between 2010 and 2020 were analyzed in a systematic literature review using the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. Data regarding demographics, presentation, diagnosis, treatment, and outcome were collected.

RESULTS

We identified four cases of SN-HPC in the nasal cavity in our institution and an additional 53 cases in previous reports. The mean age at the time of diagnosis was 59 years, with a 1.2:1 male to female ratio. SN-HPC mostly appears unilaterally, arising in the ethmoid sinus (42.1%). The most common presenting symptoms were epistaxis (47.3) and nasal obstruction (47.3%). Both computed tomography (CT) and magnetic resonance imaging (MRI) were required for diagnosis and for tailoring the treatment plan. Endoscopic surgical excision was used in 85.9% of the patients, and in 15.7%, an additional preoperative embolization was performed, which was associated with septal necrosis in one patient (2.6%). The recurrence rate was 7%.

CONCLUSION

Although previous reports attribute an aggressive tumoral behavior to SN-HPC, our experience and the literature review support a more indolent course with low recurrence rates following complete endoscopic resection. Preoperative embolization can be useful in certain cases, but due to potential complications, it should not be routinely indicated.

Prior endoscopic resection does not affect the outcome of secondary surgery for T1 colorectal cancer, a systematic review and meta-analysis

BACKGROUND

It remains unclear the effect of prior endoscopic resection (ER) on the secondary surgery (SS) for T1 colorectal cancer (CRC). This study aimed to compare the short- and long-term outcomes between primary surgery (PS) and ER followed by SS for T1 CRC.

METHODS

A systematic literature search was performed in PubMed and Ovid for studies comparing PS with ER followed by SS for T1 colorectal cancer. The last search was performed on 18 May 2021. The primary outcomes were surgical parameters and the secondary outcomes were survival indicators. The meta-analysis was performed with Review Manager Software (version 5.3).

RESULTS

A total of fifteen studies published between 2013 and 2021 with 4349 patients were included in this meta-analysis finally. No significant difference was observed between the two groups for operative time (P = 0.75, WMD = 3.16, 95%CI [-15.88, 22.19], I² = 64%), blood loss (P = 0.86, WMD = 12.33, 95%CI [-122.99, 147.65], I² = 95%), and postoperative complications (P = 0.59, OR = 0.93, 95%CI [0.71, 1.22], I² = 0%). Besides, the two groups showed comparable survival outcomes, including overall recurrence rate (P = 0.15, OR = 0.78, 95%CI [0.56, 1.09], I² = 23%) and 5-year overall survival (P = 0.76, OR = 0.86, 95%CI [0.33, 2.25], I² = 0%). In the subgroup analysis for studies with propensity matching score or lesions located in the rectum, the results were not changed.

CONCLUSION

ER followed by SS is feasible for T1 CRC with high-risk factors. The prior ER would not bring additional adverse effects to the SS. More advanced tools should be developed to improve the diagnostic accuracy for the high-risk factors before treatment for T1 CRC.

Vertical tumor margin of endoscopic resection for T1 colorectal carcinoma affects the prognosis of patients undergoing additional surgery

BACKGROUND

Vertical tumor margin-negative T1 colorectal carcinoma (CRC) is an absolute curative condition following complete endoscopic resection (ER). However, the influence on prognosis in relation to vertical tumor margin is unclear. Therefore, we evaluated the influence of the distance from vertical tumor margin to resected specimen edge (vertical margin distance) of ER for T1b (submucosal invasion depth > 1000 μm) CRC on the prognosis of patients undergoing additional surgery after ER.

METHODS

In total, 215 consecutive patients with T1b CRC who underwent additional surgery after ER at Hiroshima University Hospital between February 1992 and June 2019 were enrolled. We assessed 191 patients without lymph node metastases at the additional surgery. The specimens resected by ER were classified into three groups based on the vertical margin distance: patients with a vertical margin distance of ≥ 500 μm (Group A); patients with a vertical margin distance of < 500 μm (Group B); and patients with a positive vertical tumor margin (Group C). Subsequently, we evaluated the prognosis of the patients in relation to the clinicopathological characteristics among the three groups.

RESULTS

There were no significant differences in clinicopathological characteristics among the three groups. Group A had a significantly higher recurrence-free 5-year survival rate than Groups B and C (100%, 84.5%, and 81.8%, respectively). Similarly, Group A had a significantly higher disease-specific 5-year survival rate than Group C (100% vs. 95.5%).

CONCLUSIONS

Complete en bloc resection with sufficient submucosal layer from the invasive front (vertical margin distance > 500 μm) by ER for T1 CRC reduces the risk of metastatic recurrence after additional surgery.

Sporadic non-ampullary duodenal adenomas: efficacy and outcomes of endoscopic resection

BACKGROUND AND AIMS

Sporadic non-ampullary duodenal adenomas (SNDAs) are often referred to tertiary centers because of the challenges in endoscopic resection. There is a paucity of data on both technical and clinical outcomes. The aim of our study was to evaluate the efficacy and safety of endoscopic resection for the treatment of SNDA in two western centers.

METHODS

This is a retrospective study reporting data of a cohort of patients referred for resection of SNDA between 2013 and 2017. Patients with familial adenomatous polyposis or ampullary lesions were excluded from present analysis. Outcomes considered for this study were technical success, adverse events, recurrence and need for surgery.

RESULTS

120 patients (mean age 66 ± 11.9 years, 64male) were enrolled in the study. Mean size of the lesions was 23.3 mm (range 5-80). Fifty-six en-bloc endoscopic mucosal resection (EMR) (46.6%), 41 piecemeal EMR (pEMR) and 23 endoscopic submucosal dissection were performed. Intra-procedural perforation was observed in 4 patients (3.3%). Fourteen post-procedural (11.6%) adverse events were recorded. All post-procedural perforations occurred in lesions > 30 mm. Recurrence was observed in 11 patients (9.5%) during a mean follow-up of 29 months. All recurrences were successfully managed endoscopically. 119 patients were still alive at last follow-up.

CONCLUSION

Endoscopic resection can be successfully carried out in majority of patients. Size > 30 mm seems to be the predictor of high adverse events risk.