1
|
Okimoto K, Matsumura T, Matsusaka K, Ohta Y, Taida T, Kato J, Kato N. Successful closure of large mucosal defect with novel anchor-pronged clip after gastric endoscopic submucosal dissection. Endoscopy 2024; 56:E534-E535. [PMID: 38917972 PMCID: PMC11199051 DOI: 10.1055/a-2334-1103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Affiliation(s)
- Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Endoscopy Center, Chiba University Hospital, Chiba, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Endoscopy Center, Chiba University Hospital, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
2
|
Inada T, Sumida Y, Homma H, Maehara K, Shiotsuki K, Fukuda SI, Akiho H. Novel clip method for endoscopic submucosal dissection defect closure reducing submucosal dead space in antithrombotic gastric patients. Endoscopy 2024; 56:E45-E46. [PMID: 38232769 PMCID: PMC10794086 DOI: 10.1055/a-2223-4475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Taisuke Inada
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Hitoshi Homma
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Kosuke Maehara
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Kazuo Shiotsuki
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Shin-ichiro Fukuda
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Hirotada Akiho
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| |
Collapse
|
3
|
Goto O, Morita Y, Takayama H, Hirasawa K, Sato C, Oyama T, Takahashi A, Abe S, Saito Y, Ono H, Kawata N, Otsuka T, Iwakiri K. Endoscopic hand suturing has the potential to reduce bleeding after gastric endoscopic submucosal dissection in patients on antithrombotic agents: Multicenter phase II study. Dig Endosc 2024. [PMID: 39193787 DOI: 10.1111/den.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/31/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVES The risk of postoperative bleeding is high after gastric endoscopic submucosal dissection (ESD) in patients continuously treated with antithrombotic agents (ATAs). The effectiveness of endoscopic hand suturing (EHS) on bleeding after gastric ESD was investigated in patients at high risk of delayed bleeding. METHODS Patients with neoplasms ≤2 cm who underwent gastric ESD and continued to receive perioperative ATAs were enrolled in this multicenter phase II study. The mucosal defect was closed with EHS after removing the lesion. Postoperative bleeding rate was assessed for 3-4 postoperative weeks as a primary outcome measure. The technical success of EHS and adverse events were also assessed. Based on expected and threshold postoperative bleeding rates of 10% and 25%, respectively, we aimed to include 48 patients in the study. RESULTS A total of 49 patients were enrolled in the study, and 43 patients were finally registered as the per-protocol set. The postoperative bleeding rate was 7.0% (3/43 patients; the upper limit of one-sided 95% confidence interval [CI], 17.1% and 97.5% CI, 19.1%). The upper limits of the CI were below the threshold value (25%), and the postoperative bleeding rate was below the expected value (10%). The technical EHS success rate, closure maintenance rate on postoperative day 3, and postoperative subclinical bleeding rate were 100%, 83%, and 2%, respectively. No severe adverse events related to EHS were observed. CONCLUSIONS Endoscopic hand suturing may prevent postoperative bleeding in patients undergoing gastric ESD while being treated continuously with ATAs (UMIN000038140).
Collapse
Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
- Endoscopy Center, Nippon Medical School Hospital, Tokyo, Japan
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University International Clinical Cancer Research Center, Hyogo, Japan
| | - Hiroshi Takayama
- Department of Gastroenterology, Kobe University International Clinical Cancer Research Center, Hyogo, Japan
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center, Kanagawa, Japan
| | - Chiko Sato
- Division of Endoscopy, Yokohama City University Medical Center, Kanagawa, Japan
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Akiko Takahashi
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
- Center for Clinical Research, Nippon Medical School Hospital, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
4
|
Cai Q, Chen H, Hou H, Dong W, Zhang L, Shen M, Yi S, Xie R, Hou X, Lan W, He Y, Yang D. A novel twin-grasper assisted mucosal inverted closure technique for closing large artificial gastric mucosal defects. Surg Endosc 2024; 38:460-468. [PMID: 37985489 PMCID: PMC10776692 DOI: 10.1007/s00464-023-10552-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/19/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Large artificial gastric mucosal defects are always left unclosed for natural healing due to technique difficulties in closure. This study aims to evaluate the feasibility and safety of a new Twin-grasper Assisted Mucosal Inverted Closure (TAMIC) technique in closing large artificial gastric mucosal defects. METHODS Endoscopic submucosal dissection (ESD) was performed in fifteen pigs to create large gastric mucosal defects. The mucosal defects were then either left unclosed or closed with metallic clips using TAMIC technique. Successful closure rate and the wound outcomes were assessed. RESULTS Two mucosal defects with size of about 4.0 cm were left unclosed and healed two months after surgery. Thirteen large gastric mucosal defects were created by ESD with a medium size of 5.9 cm and were successfully closed with the TAMIC technique (100%), even in a mucosal defect with a width up to 8.5 cm. The mean closure time was 59.0 min. Wounds in eight stomachs remained completely closed 1 week after surgery (61.5%), while closure in the other five stomachs had partial wound dehiscence (38.5%). Four weeks later, all the closed defects healed well and 61.5% of the wounds still remained completely closed during healing. There was no delayed perforation or bleeding after surgery. In addition, there was less granulation in the submucosal layer of the closed wound sites than those under natural healing. CONCLUSIONS The present study suggests that TAMIC is feasible and safe in closing large artificial gastric mucosal defects and could improve mucosal recovery compared to natural healing process.
Collapse
Affiliation(s)
- Qinbo Cai
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Huanjie Chen
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haobin Hou
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wenqing Dong
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Department of Endoscopy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Lele Zhang
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Minxuan Shen
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shaoxiong Yi
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Rongman Xie
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xun Hou
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China
| | - Wentong Lan
- Department of Endoscopy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Yulong He
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China.
- Digestive Diseases Center, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China.
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, Shenzhen, China.
| | - Dongjie Yang
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat Sen University, Guangzhou, China.
- Digestive Diseases Center, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China.
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, Shenzhen, China.
| |
Collapse
|
5
|
Goto O. How should we evaluate the efficacy of endoscopic closure appropriately? A black box between interventions and outcomes. Endoscopy 2023; 55:773-774. [PMID: 37137328 DOI: 10.1055/a-2073-3608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Osamu Goto
- Endoscopy Center, Nippon Medical School Hospital, Tokyo, Japan
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
6
|
Nomura T, Sugimoto S, Temma T, Oyamada J, Ito K, Kamei A. Suturing techniques with endoscopic clips and special devices after endoscopic resection. Dig Endosc 2023; 35:287-301. [PMID: 35997063 DOI: 10.1111/den.14427] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/21/2022] [Indexed: 12/07/2022]
Abstract
Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.
Collapse
Affiliation(s)
- Tatsuma Nomura
- Department of Gastroenterology, Mie Prefectural Shima Hospital, Mie, Japan.,Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Shinya Sugimoto
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Taishi Temma
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Jun Oyamada
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Keichi Ito
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Akira Kamei
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| |
Collapse
|
7
|
Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023; 35:216-231. [PMID: 35778927 DOI: 10.1111/den.14397] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/30/2022] [Indexed: 01/24/2023]
Abstract
Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.
Collapse
Affiliation(s)
- Hideki Kobara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Naoya Tada
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shintaro Fujihara
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Noriko Nishiyama
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| |
Collapse
|
8
|
Nomura T, Sugimoto S, Temma T, Oyamada J, Ito K, Kamei A. Reopenable clip-over-the-line method for closing large mucosal defects following gastric endoscopic submucosal dissection: Prospective feasibility study. Dig Endosc 2022; 35:505-511. [PMID: 36346166 DOI: 10.1111/den.14466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Large mucosal defects following gastric endoscopic submucosal dissection (ESD) cause postoperative bleeding. To address this limitation and ensure closure of large mucosal defects, we developed the reopenable clip-over-the-line method (ROLM) using a reopenable clip and nylon line. The purpose of this study was to evaluate the feasibility of the ROLM for closure of large mucosal defects following gastric ESD in a prospective, consecutive series of cases. METHODS We performed the ROLM on 50 consecutive patients with gastric mucosal defects at the Ise Red Cross Hospital and Mie Prefectural Shima Hospital. The time to complete the ROLM, numbers of clips and lines required, size of defect, and closure success rate were measured, and postoperative adverse events were recorded. RESULTS In all, 50 lesions were included in this study period between July 2021 and March 2022. The success rates of defect closure and defect closure without submucosal dead space of the ROLM were both 100% (50/50), with a median ROLM time of 30 (range, 14-35) min and a median resected specimen major axis of 45 (range, 31-73) mm. The median number of reopenable clips used was 31 (range, 10-93). Following gastric ESD, two cases of post-ESD bleeding were observed during the follow-up periods. CONCLUSION Our results suggest that ROLM is a feasible strategy for complete closure of mucosal defects post-ESD without submucosal dead space. Future comparative studies with post-ESD bleeding rate as the main outcome are desirable to evaluate the efficacy of ROLM.
Collapse
Affiliation(s)
- Tatsuma Nomura
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan.,Department of Gastroenterology, Mie Prefectural Shima Hospital, Mie, Japan
| | - Shinya Sugimoto
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Taishi Temma
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Jun Oyamada
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| | - Keiichi Ito
- Department of Gastroenterology, Mie Prefectural Shima Hospital, Mie, Japan
| | - Akira Kamei
- Department of Gastroenterology, Ise Red Cross Hospital, Mie, Japan
| |
Collapse
|
9
|
Nishiyama N, Kobara H, Kobayashi N, Chiyo T, Tada N, Kozuka K, Matsui T, Yachida T, Fujihara S, Shi T, Masaki T. Efficacy of endoscopic ligation with O-ring closure for prevention of bleeding after gastric endoscopic submucosal dissection under antithrombotic therapy: a prospective observational study. Endoscopy 2022; 54:1078-1084. [PMID: 35213923 PMCID: PMC9613440 DOI: 10.1055/a-1782-3448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/07/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND We examined the efficacy of a novel endoscopic ligation technique with O-ring closure (E-LOC) to prevent bleeding after gastric endoscopic submucosal dissection (ESD) under antithrombotic therapy. METHODS This single-center prospective study involved consecutive patients who were taking antithrombotic agents and underwent gastric ESD. E-LOC was performed by anchoring the nylon loop with hemoclips on both defect edges and/or the exposed muscle layer, and using O-ring band ligation around these deployed clips. The primary outcome was post-ESD bleeding rate. Secondary outcomes were complete closure rate, procedure time, sustained closure rate, and complications. RESULTS 48 patients were finally analyzed. The post-ESD bleeding rate was 0 %, the complete closure rate was 97.9 %, and the mean closure time was 29.9 minutes. The sustained closure rate was 95.8 % at postoperative day 2-3 and 33.3 % at postoperative day 10-11. No complications occurred. CONCLUSION E-LOC may be an effective option for closing mucosal defects after gastric ESD under antithrombotic therapy. However, the preventive effect on post-ESD bleeding should be further investigated in high risk groups.
Collapse
Affiliation(s)
- Noriko Nishiyama
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Nobuya Kobayashi
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Taiga Chiyo
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Naoya Tada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kazuhiro Kozuka
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takanori Matsui
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tatsuo Yachida
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shintaro Fujihara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tingting Shi
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| |
Collapse
|
10
|
Nakaoka M, Chiba H, Yamada K, Okada N, Arimoto J, Kuwabara H, Goto T. Successful mucosal closure of artificial gastric ulcer with twin grasping forceps and endoclips after endoscopic submucosal dissection. Endoscopy 2022; 54:E600-E601. [PMID: 34933369 DOI: 10.1055/a-1711-4091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| | - Keiji Yamada
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| | - Naoya Okada
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| | - Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| | - Toru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, Chuo, Ota-Ku, Tokyo, Japan
| |
Collapse
|
11
|
Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis. Polymers (Basel) 2022; 14:polym14122387. [PMID: 35745963 PMCID: PMC9227627 DOI: 10.3390/polym14122387] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/20/2022] [Accepted: 06/09/2022] [Indexed: 01/27/2023] Open
Abstract
New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.
Collapse
|
12
|
Liu L, Liu H, Feng Z. A narrative review of postoperative bleeding in patients with gastric cancer treated with endoscopic submucosal dissection. J Gastrointest Oncol 2022; 13:413-425. [PMID: 35284137 PMCID: PMC8899759 DOI: 10.21037/jgo-21-466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/28/2021] [Indexed: 11/14/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is now considered a standard treatment for selected patients with early gastric cancer. Compared with endoscopic mucosal resection (EMR), ESD provides a higher complete resection rate (R0), and therefore, a lower local recurrence rate. However, ESD is a more time-consuming procedure, creating a wider and deeper ulcer floor which may cause complications. Post-ESD bleeding is one of them. Although most post-ESD bleedings can be controlled by endoscopic hemostasis at the time of operation, some bleeding after ESD may result in serious conditions such as hemorrhagic shock. Even with preventive methods such as ulcer closure, the application of fibrin glue and polyglycolic acid shielding, acid secretion inhibitors and hemostasis on second-look endoscopy, our experiences told us that post-ESD bleeding cannot be entirely avoidable, especially for patients with big size ulcer bed, anticoagulants/antithrombosis and chronic kidney diseases. The present review first defined post-ESD bleeding, then the incidence, the risk factors, such as the location of operative lesion, the size and depth, chronic kidney diseases, the impacts of anticoagulant and antithrombotic agents. We finally reviewed the managements of post-ESD bleeding, including approaches of coagulating potential bleeding spots during the procedure, lesion closure, lesion shielding and the application of gastric acid secretion inhibitors.
Collapse
Affiliation(s)
- Li Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hongqun Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- G.I. research group, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhijie Feng
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
13
|
Goto O, Kaise M, Iwakiri K. What's New with Endoscopic Treatments for Early Gastric Cancer in the "Post-ESD Era"? Digestion 2022; 103:92-98. [PMID: 34518449 DOI: 10.1159/000518892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic treatments for gastric cancers have still been progressing even after the great success of endoscopic submucosal dissection (ESD). SUMMARY In further advancements of ESD, safe and less-invasive procedures are challenged by managing postoperative bleeding, one of the major adverse events in ESD. Covering the mucosal defect after removal of lesions appears reasonable and effective for preventing delayed bleeding from the post-ESD ulcers. Shielding with biodegradable sheets is attempted on clinical trials, which show equivocal results. Although suturing of the mucosal rims is technically challenging, pilot studies demonstrate favorable outcomes for avoiding post-ESD bleeding even in cases at high risk. In cases after noncurative resection of ESD, the selection of patients who truly require additional gastrectomy with lymph node dissection is important to provide necessary surgery. Risk stratification of lymph node metastases and surgery has been developed, which offers tailor-made management to each patient considering the risks and benefits. In surgery, function-preserving gastrectomy to minimize the resection area in both lymphadenectomy and the primary site is clinically introduced. The sentinel node navigation surgery is promising to realize the minimally invasive gastrectomy, and it should strongly fit ESD as well as laparoscopic endoscopic cooperative surgery or endoscopic full-thickness resection, although nonexposure approaches are desirable. Key Message: Development for less-invasive managements on gastric cancer will be continued in step with the advancement of endoscopic treatments.
Collapse
Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
14
|
Akimoto T, Goto O, Sasaki M, Mizutani M, Tsutsumi K, Kiguchi Y, Takatori Y, Nakayama A, Kato M, Fujimoto A, Ochiai Y, Maehata T, Kaise M, Iwakiri K, Yahagi N. Endoscopic hand suturing for mucosal defect closure after gastric endoscopic submucosal dissection may reduce the risk of postoperative bleeding in patients receiving antithrombotic therapy. Dig Endosc 2022; 34:123-132. [PMID: 34021512 DOI: 10.1111/den.14045] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Endoscopic hand suturing (EHS) is expected to decrease the risk of post-endoscopic submucosal dissection (ESD) bleeding by closing mucosal defects. We investigated the efficacy of EHS after gastric ESD in patients with antithrombotic agents. METHODS In this prospective single-arm trial, patients taking antithrombotic agents for cardiovascular disease, arrhythmia, cerebrovascular disease and/or peripheral arterial disease and having <3-cm gastric neoplasms were recruited. The mucosal defects after ESD were closed by EHS in which the needle was delivered through an overtube, and the mucosal rim of the defect was continuously sutured in a linear fashion by manipulating the needle grasped with the needle holder, followed by cutting the remnant suture and retrieval of the needle. The primary endpoint was the incidence of postoperative bleeding within 4 weeks after ESD. RESULTS Twenty-two lesions in 20 patients (continuing antiplatelet agents in 11, anticoagulant agents in eight, both in one) underwent ESD followed by EHS. All defects (median size, 30 mm; range, 12-51 mm) were completely closed by EHS and remained closed on postoperative day 3. The median number of stitches was six (range, 4-8) and median suturing time was 36 (range, 24-60) min. There were no adverse events during/after EHS or postoperative bleeding. CONCLUSIONS Postoperative bleeding was not observed in patients taking antithrombotic agents without perioperative cessation. EHS appears to be useful for prevention of post-gastric ESD bleeding in high-risk patients. (Clinical registration number: UMIN000024184).
Collapse
Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Koshiro Tsutsumi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Kiguchi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
15
|
Minato Y, Mori H, Ito F. Endoscopic suturing using a new device to prevent adverse events after endoscopic submucosal dissection: Double-arm-bar Suturing System. Dig Endosc 2022; 34:e9-e11. [PMID: 34668242 DOI: 10.1111/den.14158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/26/2021] [Accepted: 10/01/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Yohei Minato
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hirohito Mori
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Fumio Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| |
Collapse
|
16
|
Sugimoto M, Hatta W, Tsuji Y, Yoshio T, Yabuuchi Y, Hoteya S, Doyama H, Nagami Y, Hikichi T, Kobayashi M, Morita Y, Sumiyoshi T, Iguchi M, Tomida H, Inoue T, Mikami T, Hasatani K, Nishikawa J, Matsumura T, Nebiki H, Nakamatsu D, Ohnita K, Suzuki H, Ueyama H, Hayashi Y, Murata M, Yamaguchi S, Michida T, Yada T, Asahina Y, Narasaka T, Kuribayashi S, Kiyotoki S, Mabe K, Fujishiro M, Masamune A, Kawai T. Risk Factors for Bleeding After Endoscopic Submucosal Dissection for Gastric Cancer in Elderly Patients Older Than 80 Years in Japan. Clin Transl Gastroenterol 2021; 12:e00404. [PMID: 34644281 PMCID: PMC8659993 DOI: 10.14309/ctg.0000000000000404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/05/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION As the aging of people in a society advances, the number of elderly patients older than 80 years in Japan with gastric cancer continues to increase. Although delayed ulcer bleeding is a major adverse event after endoscopic submucosal dissection (ESD), little is known about characteristic risk factors for bleeding in elderly patients undergoing ESD. This study aimed to evaluate risk factors for delayed bleeding after ESD for gastric cancer in elderly patients older than 80 years. METHODS We retrospectively evaluated the incidence of delayed bleeding after ESD in 10,320 patients with early-stage gastric cancer resected by ESD between November 2013 and January 2016 at 33 Japanese institutions and investigated risk factors for delayed bleeding in elderly patients older than 80 years. RESULTS The incidence of delayed bleeding in elderly patients older than 80 years was 5.7% (95% confidence interval [CI]: 4.6%-6.9%, 95/1,675), which was significantly higher than that in nonelderly (older than 20 years and younger than 80 years) patients (4.5%, 4.1%-5.0%, 393/8,645). Predictive factors for ESD-associated bleeding differed between nonelderly and elderly patients. On multivariate analysis of predictive factors at the time of treatment, risk factors in elderly patients were hemodialysis (odds ratio: 4.591, 95% CI: 2.056-10.248, P < 0.001) and warfarin use (odds ratio: 4.783, 95% CI: 1.689-13.540, P = 0.003). DISCUSSION This multicenter study found that the incidence of delayed bleeding after ESD in Japanese patients older than 80 years was high, especially in patients receiving hemodialysis and taking warfarin. Management of ESD to prevent delayed bleeding requires particular care in patients older than 80 years.
Collapse
Affiliation(s)
- Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo, Japan
- Division of Digestive Endoscopy, Shiga University of Medical Science Hospital, Shiga, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University International Clinical Cancer Research Center, Kobe, Japan
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hideomi Tomida
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takuya Inoue
- Division of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Japan
| | - Jun Nishikawa
- Faculty of Laboratory Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Ken Ohnita
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Haruhisa Suzuki
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masaki Murata
- Division of Digestive Endoscopy, Shiga University of Medical Science Hospital, Shiga, Japan
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Tomoki Michida
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama, Japan
- Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomoyuki Yada
- Division of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| | - Yoshiro Asahina
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Toshiaki Narasaka
- Division of Endoscopic Center, University of Tsukuba Hospital, Tsukuba, Japan
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo, Japan
| |
Collapse
|
17
|
Shiotsuki K, Takizawa K, Notsu A, Kakushima N, Kawata N, Yoshida M, Yabuuchi Y, Kishida Y, Ito S, Imai K, Ishiwatari H, Hotta K, Matsubayashi H, Ono H. Endoloop closure following gastric endoscopic submucosal dissection to prevent delayed bleeding in patients receiving antithrombotic therapy. Scand J Gastroenterol 2021; 56:1117-1125. [PMID: 34415223 DOI: 10.1080/00365521.2021.1949491] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Given the high risk of bleeding in post-endoscopic submucosal dissection (ESD) patients receiving antithrombotic therapy, a new effective method is needed to prevent delayed bleeding among such patients. The aim of this study was to assess the efficacy of endoloop closure, using an endoloop and clips, after gastric ESD to prevent bleeding among patients receiving antithrombotic therapy. METHODS This retrospective study enrolled patients taking antithrombotic agents who underwent ESD for early gastric cancer between March 2016 and January 2019. Patients were classified into two groups: the endoloop closure group and the control group (no prophylactic treatment). We compared the rates of post-endoscopic submucosal dissection bleeding between the two groups. RESULTS Overall, 178 patients were included, with 37 patients in the endoloop closure group and 141 patients in the control group. The rate of post-endoscopic submucosal dissection bleeding was in general lower in the endoloop closure group than in the control group; however, the difference was not statistically significant (8% vs. 23%, p = 0.06). Among patients with a resected specimen size <40 mm and those using multiple antithrombotic agents, the endoloop closure group showed a lower rate of post-endoscopic submucosal dissection bleeding (0% vs. 16%, p = 0.03 and 10% vs. 70%, p = 0.02, respectively). CONCLUSIONS Closure using an endoloop and endoclips after gastric ESD might prevent post-procedure bleeding in patients receiving antithrombotic therapy, particularly in those patients with a resected specimen <40 mm and those receiving multiple antithrombotic agents.
Collapse
Affiliation(s)
- Kazuo Shiotsuki
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akifumi Notsu
- Clinical Research Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| |
Collapse
|
18
|
Endoscopic Closure Utilizing Endoloop and Endoclips After Gastric Endoscopic Submucosal Dissection for Patients on Antithrombotic Therapy. Dig Dis Sci 2021; 66:2336-2344. [PMID: 32797345 DOI: 10.1007/s10620-020-06508-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Antithrombotic therapy is a well-known independent risk factor for bleeding after endoscopic submucosal dissection (ESD) of early gastric cancer (EGC). A novel method of ulcer base closure using an endoloop and endoclips has been reported. This study aimed to evaluate the effectiveness of endoscopic closure using an endoloop and endoclips in preventing post-ESD bleeding in patients undergoing gastric ESD on antithrombotic therapy. METHODS This was a single center, retrospective study. Patients on antithrombotic therapy who underwent gastric ESD were divided into two groups, the closure group and the non-closure group. We analyzed procedural outcomes, post-ESD bleeding rate and factors associated with post-ESD bleeding. RESULTS Among 400 ESDs with EGCs in 311 patients, 131 ESDs in 110 patients were in the closure group, and 269 ESDs in 217 patients were in the non-closure group (16 patients were overlapped in both groups). Post-ESD bleeding rate was 11.5% (15/131) in the closure group, and 11.9% (32/269) in the non-closure group (p = 0.89). Total sustained closure rate during second look endoscopy was 47.8% (33/69). Post-ESD bleeding rate tended to be lower in the closure group than in the non-closure group for lesions located in the greater curvature (3.6% vs. 11.1%, p = 0.11). In addition, sustained closure rate was significantly higher in the greater curvature than in the lesser curvature (72.0% vs. 34.1%, p < 0.01). Multivariate analysis revealed resection size > 40 mm and heparin bridge were the independent risk factor for post-ESD bleeding. CONCLUSION Ulcer base closure using endoloop and endoclips did not prevent post-ESD bleeding in patients on antithrombotic therapy.
Collapse
|
19
|
Misumi Y, Nonaka K. Prevention and Management of Complications and Education in Endoscopic Submucosal Dissection. J Clin Med 2021; 10:jcm10112511. [PMID: 34204078 PMCID: PMC8201364 DOI: 10.3390/jcm10112511] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is considered superior to endoscopic mucosal resection as an endoscopic resection because of its higher en bloc resection rate, but it is more difficult to perform. As ESD techniques have become more common, and the range of treatment by ESD has expanded, the number of possible complications has also increased, and endoscopists need to manage them. In this report, we will review the management of critical complications, such as hemorrhage, perforation, and stenosis, and we will also discuss educational methods for acquiring and improving ESD skills.
Collapse
|
20
|
Goto O, Koizumi E, Higuchi K, Noda H, Onda T, Omori J, Kaise M, Iwakiri K. Cutting-Edge Technologies for Gastrointestinal Therapeutic Endoscopy. J NIPPON MED SCH 2021; 88:17-24. [PMID: 33692281 DOI: 10.1272/jnms.jnms.2021_88-109] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
With advancements in the development of flexible endoscopes and endoscopic devices and the increased demand for minimally invasive treatments, the indications of therapeutic endoscopy have been expanded. Methods of endoscopic treatment used for tissue removal, hemostasis, and dilatation are as follows. Endoscopic submucosal dissection (ESD) is considered the gold standard curative method for removal of gastrointestinal node-negative neoplasms, regardless of their size or the presence of ulcer formation. Laparoscopic endoscopic cooperative surgery (LECS), which incorporates ESD, was introduced for removal of lesions in deeper layers. Another technique is endoscopic full-thickness resection, which is challenging without the assistance of laparoscopy. In terms of hemostasis, management of iatrogenic bleeding after endoscopic treatment is an important issue. Shielding methods and suturing techniques have been introduced for large mucosal defects after ESD, and their efficacy has been investigated clinically. Peroral endoscopic myotomy (POEM) is a new alternative surgical approach for minimally invasive treatment of esophageal achalasia. Furthermore, endoscopic fundoplication after POEM was devised to prevent post-POEM gastroesophageal reflux disease. Many endoscopic treatments, including ESD, LECS, and POEM, have been introduced in Japan. With the aging of the population, more attention will be directed toward therapeutic endoscopy for elderly patients, because it is less invasive. Development of endoscopic treatments with expanded indications is expected.
Collapse
Affiliation(s)
- Osamu Goto
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Eriko Koizumi
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Kazutoshi Higuchi
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Hiroto Noda
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Takeshi Onda
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Jun Omori
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Mitsuru Kaise
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Katsuhiko Iwakiri
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| |
Collapse
|
21
|
Hatta W, Tsuji Y, Yoshio T, Kakushima N, Hoteya S, Doyama H, Nagami Y, Hikichi T, Kobayashi M, Morita Y, Sumiyoshi T, Iguchi M, Tomida H, Inoue T, Koike T, Mikami T, Hasatani K, Nishikawa J, Matsumura T, Nebiki H, Nakamatsu D, Ohnita K, Suzuki H, Ueyama H, Hayashi Y, Sugimoto M, Yamaguchi S, Michida T, Yada T, Asahina Y, Narasaka T, Kuribasyashi S, Kiyotoki S, Mabe K, Nakamura T, Nakaya N, Fujishiro M, Masamune A. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut 2021; 70:476-484. [PMID: 32499390 PMCID: PMC7873424 DOI: 10.1136/gutjnl-2019-319926] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is a frequent adverse event after ESD. We aimed to develop and externally validate a clinically useful prediction model (BEST-J score: Bleeding after ESD Trend from Japan) for bleeding after ESD for EGC. DESIGN This retrospective study enrolled patients who underwent ESD for EGC. Patients in the derivation cohort (n=8291) were recruited from 25 institutions, and patients in the external validation cohort (n=2029) were recruited from eight institutions in other areas. In the derivation cohort, weighted points were assigned to predictors of bleeding determined in the multivariate logistic regression analysis and a prediction model was established. External validation of the model was conducted to analyse discrimination and calibration. RESULTS A prediction model comprised 10 variables (warfarin, direct oral anticoagulant, chronic kidney disease with haemodialysis, P2Y12 receptor antagonist, aspirin, cilostazol, tumour size >30 mm, lower-third in tumour location, presence of multiple tumours and interruption of each kind of antithrombotic agents). The rates of bleeding after ESD at low-risk (0 to 1 points), intermediate-risk (2 points), high-risk (3 to 4 points) and very high-risk (≥5 points) were 2.8%, 6.1%, 11.4% and 29.7%, respectively. In the external validation cohort, the model showed moderately good discrimination, with a c-statistic of 0.70 (95% CI, 0.64 to 0.76), and good calibration (calibration-in-the-large, 0.05; calibration slope, 1.01). CONCLUSIONS In this nationwide multicentre study, we derived and externally validated a prediction model for bleeding after ESD. This model may be a good clinical decision-making support tool for ESD in patients with EGC.
Collapse
Affiliation(s)
- Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Centre, Shizuoka, Japan
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Mikitaka Iguchi
- Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hideomi Tomida
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takuya Inoue
- Division of Gastroenterology and Hepatology, Osaka General Medical Centre, Osaka, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Japan
| | - Jun Nishikawa
- Faculty of Laboratory Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Ken Ohnita
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Haruhisa Suzuki
- Endoscopy Division, National Cancer Centre Hospital, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Mitsushige Sugimoto
- Division of Digestive Endoscopy, Shiga University of Medical Science Hospital, Otsu, Japan,Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo, Japan
| | | | - Tomoki Michida
- Department of Gastroenterology and Hepatology, Saitama Medical Centre, Saitama, Japan
| | - Tomoyuki Yada
- Division of Gastroenterology & Hepatology, Kohnodai Hospital, National Centre for Global Health and Medicine, Ichikawa, Japan
| | - Yoshiro Asahina
- Division of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Tsukuba, Japan
| | - Shiko Kuribasyashi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
| | - Tomohiro Nakamura
- Department of Health Record Informatics, Tohoku Medical Megabank Organization, Sendai, Japan
| | - Naoki Nakaya
- Department of Health Sciences, Saitama Prefectural University, Koshigaya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
22
|
Yamamoto Y, Yahagi N, Yamamoto H, Ono H, Inoue H. Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions. Dig Endosc 2020; 32:882-887. [PMID: 32415998 DOI: 10.1111/den.13722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022]
Abstract
Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.
Collapse
Affiliation(s)
- Yorimasa Yamamoto
- Division of Gastroenterology, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| |
Collapse
|
23
|
Akimoto T, Goto O, Sasaki M, Mizutani M, Tsutsumi K, Kiguchi Y, Nakayama A, Kato M, Fujimoto A, Ochiai Y, Maehata T, Kaise M, Iwakiri K, Yahagi N. Endoscopic suturing promotes healing of mucosal defects after gastric endoscopic submucosal dissection: endoscopic and histologic analyses in in vivo porcine models (with video). Gastrointest Endosc 2020; 91:1172-1182. [PMID: 31904381 DOI: 10.1016/j.gie.2019.12.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic suturing of mucosal defects after endoscopic submucosal dissection (ESD) is expected to prevent postoperative adverse events. We aimed to endoscopically and histologically evaluate the healing process of post-ESD mucosal defects closed with endoscopic hand suturing (EHS) in in vivo porcine models. METHODS Twelve mucosal defects (2 cm in size) were created in 2 pigs (6 defects per pig). Initially, 2 defects were created: one was closed with EHS (sutured group) and the other was kept open (control group). On postoperative days (PODs) 7 and 14, 2 additional defects were created in each session, and they were treated in the same manner as in the initial procedure. On POD 21, the entire stomach, with the 6 lesion sites, was extracted for histologic evaluation after endoscopic observation. RESULTS Endoscopically, all sutured sites remained closed in all sessions (PODs 7, 14, and 21). Histologically, on POD 14, the epithelium and muscularis mucosae were appropriately connected. The mucosae were covered with the epithelium without inversion of the mucosal edge in the sutured group, whereas the ulcer bed was exposed in the control group. Furthermore, the degree of neovascularity and fibroblasts in the submucosa was smaller in the sutured group than that in the control group. CONCLUSIONS Our findings suggest that endoscopic suturing promotes healing of post-ESD mucosal defects histologically in in vivo porcine models. Thus, endoscopic mucosal closure after ESD might be clinically useful for the prevention of delayed perforation/bleeding if secure suturing is performed endoscopically.
Collapse
Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo; Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo; Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Koshiro Tsutsumi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Yoshiyuki Kiguchi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | | | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| |
Collapse
|
24
|
Goto O, Oyama T, Ono H, Takahashi A, Fujishiro M, Saito Y, Abe S, Kaise M, Iwakiri K, Yahagi N. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020; 91:1195-1202. [PMID: 31923410 DOI: 10.1016/j.gie.2019.12.046] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic hand-suturing (EHS) provides secure intraluminal mucosal closure and should decrease the risk of adverse events after gastric endoscopic submucosal dissection (ESD). We prospectively investigated the feasibility and safety of EHS after gastric ESD, particularly for preventing post-ESD bleeding. METHODS Patients scheduled for gastric ESD at 3 institutions were prospectively recruited. Just after ESD, the mucosal defect was closed by EHS. The primary outcome was endoscopic assessment of adequately sustained closure of the defect on postoperative day 3. Endoscopy was performed to assess maintenance of the closure for the primary outcome. During postoperative weeks 3 to 4, patients were interviewed as outpatients about any occurrence of delayed bleeding. RESULTS Data from 30 patients (15 each who did or did not take antithrombotic agents) were analyzed. Mucosal closure by EHS was completed in 29 of 30 cases (97%) and was well maintained on postoperative day 3 in 25 cases (84%). Emergency endoscopy was required for major postoperative bleeding in 3 cases (10%), including 1 in which suturing had been incomplete. Excluding 1 patient with a remnant stomach, the other 24 with sustained closure had no bleeding, regardless of whether they did or did not take antithrombotic agents (0/11 and 0/13, respectively). No serious adverse events occurred during EHS. CONCLUSIONS Results show that EHS is feasible and safe with favorable outcomes. Provided that mucosal suturing is successfully completed and sustained, post-ESD bleeding can be decreased even in patients undergoing antithrombotic therapy. (Clinical trial registration number: UMIN 000033988.).
Collapse
Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Tsuneo Oyama
- Division of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akiko Takahashi
- Division of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukata Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Department for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
25
|
Chang K, Lee BS, Tekeste T, Nguyen A, Adeyemo M, Girgis A, Kwok KK, Crowson HM, Burris AO, Attam R, Chaya CT, Durbin TE, Giap AQ, Hunt GC, Iskander J, Kao KT, Lim BS. The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study. BMC Gastroenterol 2020; 20:60. [PMID: 32143633 PMCID: PMC7060595 DOI: 10.1186/s12876-020-01199-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/20/2020] [Indexed: 12/31/2022] Open
Abstract
Background Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions. Method This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage. Results A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893. Conclusion Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.
Collapse
Affiliation(s)
- Karen Chang
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Brian S Lee
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Timnit Tekeste
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Andrew Nguyen
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Mopelola Adeyemo
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Agathon Girgis
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Karl K Kwok
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA, 90027, USA
| | - H Michael Crowson
- Department of Educational Psychology, The University of Oklahoma, 820 Van Vleet Oval, Collings Hall, Room 321, Norman, OK, 73019-2041, USA
| | - Alicia O Burris
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA
| | - Rajeev Attam
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, 9353 Imperial Highway, Downey, CA, 90242, USA
| | - Charles T Chaya
- Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, 10800 Magnolia Avenue, Riverside, CA, 92505, USA
| | - Theodore E Durbin
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, 3440 E La Palma Avenue, Anaheim, CA, 92806, USA
| | - Andrew Q Giap
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, 3440 E La Palma Avenue, Anaheim, CA, 92806, USA
| | - Gordon C Hunt
- Department of Gastroenterology, Kaiser Permanente San Diego Medical Center, 9445 Clairemont Mesa Blvd, San Diego, CA, 92123, USA
| | - John Iskander
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Kevin T Kao
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, 9353 Imperial Highway, Downey, CA, 90242, USA
| | - Brian S Lim
- Department of Internal Medicine, School of Medicine, University of California, Riverside, 900 University Avenue, Riverside, CA, 92521, USA. .,Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, 10800 Magnolia Avenue, Riverside, CA, 92505, USA.
| |
Collapse
|
26
|
Yamamoto Y, Kikuchi D, Nagami Y, Nonaka K, Tsuji Y, Fujimoto A, Sanomura Y, Tanaka K, Abe S, Zhang S, De Lusong MA, Uedo N. Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts. Dig Endosc 2019; 31 Suppl 1:4-20. [PMID: 30994225 DOI: 10.1111/den.13388] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/03/2019] [Indexed: 12/15/2022]
Abstract
Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2-3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self-expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post-ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high-risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over-the-scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three-quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.
Collapse
Affiliation(s)
- Yorimasa Yamamoto
- Division of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kouichi Nonaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ai Fujimoto
- Department of Gastroenterology and Hepatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoji Sanomura
- Department of Endoscopy, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Kyosuke Tanaka
- Department of Endoscopic Medicine, Mie University Hospital, Tsu, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shuo Zhang
- Digestive Department, Zhejiang Provincial Hospital of TCM, Hangzhou, China
| | - Mark Anthony De Lusong
- Section of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| |
Collapse
|
27
|
Kawata N, Ono H, Takizawa K, Kakushima N, Tanaka M, Igarashi K, Yoshida M, Kishida Y, Iwai T, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H. Efficacy of polyglycolic acid sheets and fibrin glue for prevention of bleeding after gastric endoscopic submucosal dissection in patients under continued antithrombotic agents. Gastric Cancer 2018; 21:696-702. [PMID: 29357012 DOI: 10.1007/s10120-018-0791-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 01/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND A novel method for the prevention of bleeding after gastric endoscopic submucosal dissection (ESD) is necessary, as the numbers of patients taking antithrombotic agents have increased. This study aimed to assess the efficacy and safety of the covering method using polyglycolic acid (PGA) sheets and fibrin glue for ESD-induced ulcer in preventing post-ESD bleeding in patients under continued antithrombotic agents. METHODS One hundred five consecutive gastric tumors among 84 patients who were treated by ESD under continued antithrombotic agents between April 2014 and September 2015 were enrolled in this study. The patients were classified into two groups, the covering group (52 lesions among 38 patients; those with ESD in whom PGA sheets and fibrin glue were used as the covering method) and the control group (53 lesions among 46 patients; ESD only), and their post-ESD bleeding rates were compared. RESULTS No significant differences were seen in the number and type of antithrombotic agents, lesion location, median procedure time, and median resected specimen size between the groups. ESD was completed in all cases, with no cases of uncontrollable bleeding during the procedure. Post-ESD bleeding occurred in 5.8% (3/52) and 20.8% (11/53) in the covering and control groups, respectively. The post-ESD bleeding rate significantly differed between the groups (P = 0.04; odds ratio, 0.23; 95% confidential interval, 0.06-0.89). No adverse events were associated with the use of PGA sheets and fibrin glue. CONCLUSIONS The covering method using PGA sheets and fibrin glue has the potential to reduce post-ESD bleeding in patients receiving continued antithrombotic agents.
Collapse
Affiliation(s)
- Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan.
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Kimihiro Igarashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Tomohiro Iwai
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Sunto-gun, Nagaizumi, Shizuoka, 411-8777, Japan
| |
Collapse
|
28
|
Akimoto T, Goto O, Nishizawa T, Yahagi N. Endoscopic closure after intraluminal surgery. Dig Endosc 2017; 29:547-558. [PMID: 28181699 DOI: 10.1111/den.12839] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.
Collapse
Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| |
Collapse
|
29
|
Pioche M, Camus M, Rivory J, Leblanc S, Lienhart I, Barret M, Chaussade S, Saurin JC, Prat F, Ponchon T. A self-assembling matrix-forming gel can be easily and safely applied to prevent delayed bleeding after endoscopic resections. Endosc Int Open 2016; 4:E415-9. [PMID: 27092320 PMCID: PMC4831935 DOI: 10.1055/s-0042-102879] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/29/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Endoscopic resections have low morbidity and mortality. Delayed bleeding has been reported in approximately 1 - 15 % of cases, increasing with antiplatelet/anticoagulant therapy or portal hypertension. A self-assembling peptide (SAP) forming a gel could protect the mucosal defect during early healing. This retrospective trial aimed to assess the safety and efficacy of SAP in preventing delayed bleeding after endoscopic resections. METHODS Consecutive patients with endoscopic resections were enrolled in two tertiary referral centers. Patients with a high risk of bleeding (antiplatelet agents, anticoagulation drugs with heparin bridge therapy, and cirrhosis with portal hypertension) were also included. The SAP gel was applied immediately after resection to cover the whole ulcer bed. RESULTS In total, 56 patients were included with 65 lesions (esophagus [n = 8], stomach [n = 22], duodenum [n = 10], ampullary [n = 3], colon [n = 7], and rectum [n = 15]) in two centers. Among those 65 lesions, 29 were resected in high risk situations (9 uninterrupted aspirin therapy, 6 heparin bridge therapies, 5 cirrhosis and portal hypertension, 1 both cirrhosis and heparin bridge, 3 both cirrhosis and uninterrupted aspirin, 3 large duodenal lesions > 2 cm, and 2 early introduction of clopidogrel at day 1). The resection technique was endoscopic submucosal dissection (ESD) in 40 cases, en bloc endoscopic mucosal resection (EMR) in 16, piecemeal EMR in 6, and ampullectomy in 3. The mean lesion size was 37.9 mm (SD: 2.2 mm) with a mean area of 6.3 cm(2) (SD: 3.5 cm(2)). No difficulty was noted during application. Four delayed overt bleedings occurred (6.2 %) (3 hematochezia, 1 hematemesis) requiring endoscopic hemostasis. The mean hemoglobin drop off was 0.6 g/dL (- 0.6 to 3.1 g/dL). No adverse events occurred. CONCLUSION The use of this novel extracellular matrix scaffold may help to reduce post-endoscopic resection bleedings including in high risk situations. Its use is easy and safe but further comparative studies are warranted to completely evaluate its effectiveness.
Collapse
Affiliation(s)
- Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France,INSERM U1032, Lyon, France,University Claude Bernard Lyon 1, Lyon, France,Corresponding author Mathieu Pioche Endoscopy UnitDigestive Disease DepartmentPavillon L – Edouard Herriot Hospital69437 Lyon CedexFrance+33-4-72110147
| | - Marine Camus
- Endoscopy and Gastroenterology Unit, Assistance Publique Hôpitaux de Paris (APHP) Cochin Hospital, Paris, France,University Paris V Descartes, Paris, France
| | - Jérôme Rivory
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Sarah Leblanc
- Endoscopy and Gastroenterology Unit, Assistance Publique Hôpitaux de Paris (APHP) Cochin Hospital, Paris, France
| | - Isabelle Lienhart
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Maximilien Barret
- Endoscopy and Gastroenterology Unit, Assistance Publique Hôpitaux de Paris (APHP) Cochin Hospital, Paris, France,University Paris V Descartes, Paris, France
| | - Stanislas Chaussade
- Endoscopy and Gastroenterology Unit, Assistance Publique Hôpitaux de Paris (APHP) Cochin Hospital, Paris, France,University Paris V Descartes, Paris, France
| | - Jean-Christophe Saurin
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France,University Claude Bernard Lyon 1, Lyon, France
| | - Frederic Prat
- Endoscopy and Gastroenterology Unit, Assistance Publique Hôpitaux de Paris (APHP) Cochin Hospital, Paris, France,University Paris V Descartes, Paris, France
| | - Thierry Ponchon
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France,INSERM U1032, Lyon, France,University Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
30
|
Bahin FF, Naidoo M, Williams SJ, Hourigan LF, Ormonde DG, Raftopoulos SC, Holt BA, Sonson R, Bourke MJ. Prophylactic endoscopic coagulation to prevent bleeding after wide-field endoscopic mucosal resection of large sessile colon polyps. Clin Gastroenterol Hepatol 2015; 13:724-30.e1-2. [PMID: 25151254 DOI: 10.1016/j.cgh.2014.07.063] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/19/2014] [Accepted: 07/21/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clinically significant postendoscopic mucosal resection bleeding (CSPEB) is the most frequent significant complication of wide-field endoscopic mucosal resection (WF-EMR) of advanced mucosal neoplasia (sessile or laterally spreading colorectal lesions > 20 mm). CSPEB requires resource-intensive management and there is no strategy for preventing it. We investigated whether prophylactic endoscopic coagulation (PEC) reduces the incidence of CSPEB. METHODS We performed a prospective randomized controlled trial of 347 patients (mean age, 67.1 y; 55.3% with proximal colonic lesions) undergoing WF-EMR for advanced mucosal neoplasia at 3 Australian tertiary referral centers. Patients were assigned randomly (1:1) to groups receiving PEC (n = 172) or no additional therapy (n = 175, controls). PEC was performed with coagulating forceps, applying low-power coagulation to nonbleeding vessels in the resection defect. CSPEB was defined as bleeding requiring admission to the hospital. The primary end point was the proportion of CSPEB. RESULTS Patients in each group were similar at baseline. CSPEB occurred in 9 patients receiving PEC (5.2%) and 14 controls (8.0%; P = .30). CSPEB was associated significantly with proximal colonic location on multivariate analysis (odds ratio, 3.08; P = .03). Compared with the proximal colon, there was a significantly greater number (3.8 vs 2.1; P = .002) and mean size (0.5-1 vs 0.3-0.5 mm; P = .04) of visible vessels in the distal colon. CONCLUSIONS PEC does not significantly decrease the incidence of CSPEB after WF-EMR. There were significantly more and larger vessels in the WF-EMR mucosal defect of distal colonic lesions, yet CSPEB was more frequent with proximal colonic lesions. ClinicalTrials.gov NCT01368731.
Collapse
Affiliation(s)
- Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mahendra Naidoo
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Donald G Ormonde
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Spiro C Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Bronte A Holt
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|
31
|
Jacques J, Legros R, Chaussade S, Sautereau D. Endoscopic haemostasis: an overview of procedures and clinical scenarios. Dig Liver Dis 2014; 46:766-76. [PMID: 25022337 DOI: 10.1016/j.dld.2014.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/01/2014] [Accepted: 05/08/2014] [Indexed: 02/07/2023]
Abstract
Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.
Collapse
Affiliation(s)
- Jérémie Jacques
- Gastroenterology Department, University Hospital of Limoges, Limoges, France.
| | - Romain Legros
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
| | | | - Denis Sautereau
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
| |
Collapse
|
32
|
Maekawa S, Nomura R, Murase T, Ann Y, Harada M. Complete closure of artificial gastric ulcer after endoscopic submucosal dissection by combined use of a single over-the-scope clip and through-the-scope clips (with videos). Surg Endosc 2014; 29:500-4. [PMID: 25052125 PMCID: PMC4293458 DOI: 10.1007/s00464-014-3725-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/01/2014] [Indexed: 12/16/2022]
Abstract
Background A 5–7 day hospital stay is usually needed after endoscopic submucosal dissection (ESD) of gastric tumor because of the possibility of delayed perforation or bleeding. The aim of this study was to evaluate the efficacy of combined use of a single over-the-scope clip (OTSC) and through-the-scope clips (TTSCs) to achieve complete closure of artificial gastric ulcer after ESD. Methods We prospectively studied 12 patients with early gastric cancer or gastric adenoma. We performed complete closure of post-ESD artificial gastric ulcer using a combination of a single OTSC and TTSCs. Results Mean size of post-ESD artificial ulcer was 54.6 mm. The mean operating time for the closure procedure was 15.2 min., and the success rate was 91.7 % (11/12). Patients who underwent complete closure of post-ESD artificial gastric ulcer could be discharged the day after ESD and the closing procedure. Conclusions Complete closure of post-ESD artificial gastric ulcer using a combination of a single OTSC and TTSCs is useful for shortening the period of hospitalization and reducing treatment cost. Electronic supplementary material The online version of this article (doi:10.1007/s00464-014-3725-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Satoshi Maekawa
- Department of Gastroenterological Medicine, Japan Labour Health and Welfare Organization Niigata Rosai Hospital, 1-7-12 Touncho, Joetsu, Niigata, 942-8502, Japan,
| | | | | | | | | |
Collapse
|
33
|
Goto O, Sasaki M, Ishii H, Horii J, Uraoka T, Takeuchi H, Kitagawa Y, Yahagi N. A new endoscopic closure method for gastric mucosal defects: feasibility of endoscopic hand suturing in an ex vivo porcine model (with video). Endosc Int Open 2014; 2:E111-6. [PMID: 26135255 PMCID: PMC4424863 DOI: 10.1055/s-0034-1377180] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/17/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS More secure endoscopic closure techniques for iatrogenic gastric defects are required for safe endoscopic surgery. We developed a novel endoscopic suturing method, endoscopic hand suturing (EHS), of gastric mucosal defects and determined its feasibility and efficacy ex vivo. MATERIALS AND METHODS We created 24 mucosal defects (each 2 cm in diameter) by endoscopic submucosal dissection. The following three techniques were tested: EHS with a 3 - 0 barbed suture that was grasped with biopsy forceps (n = 6) or a prototype through-the-scope needle holder (n = 6) by endoscopy, looping with endoloops (n = 6) by endoscopy, and clipping with hemoclips (n = 6) by hand. The mucosal edges were attached to each other at three points. The closure strength was compared among the three groups, and the procedural duration was compared between the EHS and looping groups. RESULTS All 12 lesions were completely closed by EHS. The median strength of the closure, measured with a spring scale, was significantly greater in the EHS group (0.74 kg) than in the looping group (0.33 kg, P = 0.0012) or clipping group (0.07 kg, P = 0.0009). The median procedural duration did not significantly differ between the EHS and looping groups (19.7 vs. 19.8 minutes, P = 1.0000). The use of the needle holder significantly reduced the procedural duration compared with the biopsy forceps. CONCLUSION Mucosal defects can be firmly closed with EHS, which may be helpful for establishing a safer and more secure endoscopic surgery.
Collapse
Affiliation(s)
- Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine,Corresponding author Osamu Goto, MD, PhD Division of Research and Development for Minimally Invasive Treatment, Cancer CenterKeio University School of Medicine35 Shinanomachi, Shinjuku-kuTokyo 160-8582Japan+81-3-5363-3895
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine
| | - Hiroyuki Ishii
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine
| | - Joichiro Horii
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine
| |
Collapse
|
34
|
Gastric ESD under Heparin Replacement at High-Risk Patients of Thromboembolism Is Technically Feasible but Has a High Risk of Delayed Bleeding: Osaka University ESD Study Group. Gastroenterol Res Pract 2013; 2013:365830. [PMID: 23843783 PMCID: PMC3697307 DOI: 10.1155/2013/365830] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/27/2013] [Indexed: 12/14/2022] Open
Abstract
Objectives. Heparin replacement (HR) is often performed in patients with a high risk of thrombosis undergoing endoscopic procedures. However, information about the influence of HR is scarce. The aim of this study is to assess the clinical impact of HR for gastric endoscopic submucosal dissection (ESD).
Methods. This is a retrospective study comprising approximately 1310 consecutive gastric neoplasms in 1250 patients, who underwent ESD in 5 institutes. We assessed the clinical findings and outcomes of ESD under HR, compared to ESD without HR as control.
Results. A total of 24 EGC lesions in 24 patients were treated by ESD under HR. In the HR group, the complete en-bloc resection rate was 100%. The delayed bleeding rate was, however, higher in the HR group than in the controls (38% versus 4.6%). The timing of bleeding in the HR group was significantly later than in controls. In the control group, 209 patients discontinued antithrombotic therapy during perioperative period, and their delayed bleeding rate was not different from those without antithrombotic therapy (5.7% versus. 4.4%). A thromboembolic event was encountered in 1 patient under HR after delayed bleeding.
Conclusion. ESD under HR is technically feasible but has a high risk of delayed bleeding.
Collapse
|
35
|
Lee JH, Park YS, Choi KS, Kim DH, Choi KD, Song HJ, Lee GH, Jang SJ, Jung HY, Kim JH. Optimal biopsy site for Helicobacter pylori detection during endoscopic mucosectomy in patients with extensive gastric atrophy. Helicobacter 2012; 17:405-10. [PMID: 23066901 DOI: 10.1111/j.1523-5378.2012.00972.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Helicobacter pylori eradication is essential for metachronous gastric cancer prevention in patients undergoing endoscopic mucosectomy (EMR). This study was aimed to determine the optimal biopsy site for H. pylori detection in the atrophic remnant mucosa of EMR patients. MATERIAL AND METHODS Data were analyzed from 91 EMR patients. Three paired biopsies for histology were taken at antrum, corpus lesser (CLC), and greater curve (CGC). Additional specimens were obtained at antrum and CGC for rapid urease test (RUT). H. pylori infection was defined as at least two positive specimens on histology and/or RUT. Serologic atrophy was determined by pepsinogen levels. RESULTS Overall H. pylori infection rate was 72.5%. The proportions of moderate-to-marked atrophy/intestinal metaplasia at CGC (5.6/6.6%) were significantly lower than those at antrum (58.6/75.8%) and CLC (60.7/70.0%). Sensitivity of histology in detecting H. pylori was significantly higher at CGC than at antrum and CLC (84.8 vs 30.3 and 47.0%, respectively; p < .001). On RUT, detection at CGC also showed higher sensitivity than at antrum (77.3 vs 33.3%, p < .001). Specificities of all three biopsy sites were more than 90%. Regardless of serologic atrophy, CGC showed consistently higher sensitivities on histology and RUT. In patients with serologic atrophy, antral sensitivities were much lower than those of nonatrophic patients, 9.5 versus 40.0% on histology (p = .012) and 14.3 versus 42.2% on RUT (p = .025). CONCLUSIONS CGC is the optimal biopsy site for H. pylori diagnosis in EMR patients with extensive atrophy. Antral biopsy should be avoided, especially in serologically atrophic patients.
Collapse
Affiliation(s)
- Jeong Hoon Lee
- Asan Digestive Disease Research Institute, Departments of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 221] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
|
37
|
Matsumoto M, Fukunaga S, Saito Y, Matsuda T, Nakajima T, Sakamoto T, Tamai N, Kikuchi T. Risk factors for delayed bleeding after endoscopic resection for large colorectal tumors. Jpn J Clin Oncol 2012; 42:1028-34. [PMID: 22914322 DOI: 10.1093/jjco/hys131] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Endoscopic resection techniques for treating colorectal tumors have advanced recently so that large colorectal tumors can now be treated endoscopically, although some patients experience delayed bleeding after endoscopic resection. Our aim was to clarify the risk factors for delayed bleeding after endoscopic resection for colorectal tumors≥20 mm in diameter. Endoscopic submucosal dissection cases were excluded because of the low incidence of delayed bleeding after such procedures. METHODS This was a retrospective study using a prospectively completed database and patient medical records at a single, national cancer institution. A total of 403 colorectal endoscopic resections were performed on 375 consecutive patients. We analyzed the database and retrospectively assessed patient age, gender, hypertension and current use of anticoagulant (warfarin) or antiplatelet drugs (e.g. aspirin, ticlopidine) as well as tumor location, size, macroscopic type, histopathological findings, resection method and whether or not placement of prophylactic clips was performed during the endoscopic resection. RESULTS The overall rate of delayed bleeding was 4.2% (17/403) and the median interval between endoscopic resection and the onset of delayed bleeding was 2 days (range, 1-14 days). All delayed bleeding cases were successfully controlled by endoscopic hemostasis involving clipping and/or electrocoagulation without the need for surgical interventions or blood transfusions. Based on our univariate analysis, the delayed bleeding rate was significantly higher in both males (P=0.04) and those patients without prophylactic clip placement (P=0.04). CONCLUSIONS Our study results indicated that prophylactic clip placement may be an effective method for preventing delayed bleeding after endoscopic resection for large colorectal tumors.
Collapse
Affiliation(s)
- Minori Matsumoto
- Endoscopy Division, National Cancer Center Hospital, and Department of Endoscopy, The Jikei University School of Medicine, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Muraki Y, Enomoto S, Iguchi M, Fujishiro M, Yahagi N, Ichinose M. Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection. World J Gastrointest Endosc 2012; 4:1-8. [PMID: 22267977 PMCID: PMC3262173 DOI: 10.4253/wjge.v4.i1.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 11/06/2011] [Accepted: 01/12/2012] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.
Collapse
Affiliation(s)
- Yosuke Muraki
- Yosuke Muraki, Shotaro Enomoto, Mikitaka Iguchi, Masao Ichinose, Second Department of Internal Medicine, Wakayama Medical University, Wakayama-city, Wakayama 641-0012, Japan
| | | | | | | | | | | |
Collapse
|
39
|
Lee BI, Kim BW, Kim HK, Choi H, Ji JS, Hwang SM, Cho YS, Chae HS, Choi KY. Routine mucosal closure with a detachable snare and clips after endoscopic submucosal dissection for gastric epithelial neoplasms: a randomized controlled trial. Gut Liver 2011; 5:454-9. [PMID: 22195243 PMCID: PMC3240788 DOI: 10.5009/gnl.2011.5.4.454] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 03/30/2011] [Accepted: 04/10/2011] [Indexed: 12/17/2022] Open
Abstract
Background/Aims The aim of this study was to determine whether the routine closure of mucosal defects after endoscopic submucosal dissection (ESD) can enhance mucosal healing and reduce ESD-associated bleeding. Methods Patients with gastric epithelial neoplasias and no obvious submucosal invasion were prospectively enrolled. Mucosal defects were left untreated in the control group. In the study group, mucosal closure was attempted with a 2-channel endoscope, a detachable snare, and clips. All participants received a second-look endoscopy the day after ESD, and coagulation therapy was administered to patients with visible vessels and active bleeding points. Results Fifty-two patients were enrolled in the study, and 26 patients were assigned to each group. Complete mucosal defect closure occurred in 16 patients (61%) in the study group; incomplete closure occurred in 8 patients (31%) in the study group, and failed closure occurred in 2 patients (8%). Coagulation therapy at the second-look endoscopy was performed more often in the control group than in the study group (31% vs 4%, p=0.024). There were no significant differences in the incidence of immediate or delayed bleeding or in the two-week decrease in hemoglobin between the groups. The prevalence of open ulcers after 8 weeks was significantly lower in the study group than in the control group (18% vs 43%, p=0.012). Conclusions Routine mucosal closure after ESD supports earlier healing of artificial ulcers. A larger-scale trial is necessary to determine whether mucosal closure can reduce ESD-associated bleeding.
Collapse
Affiliation(s)
- Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Kim SH, Moon JS, Youn YH, Lee KM, Lee SJ. Management of the complications of endoscopic submucosal dissection. World J Gastroenterol 2011; 17:3575-9. [PMID: 21987602 PMCID: PMC3180012 DOI: 10.3748/wjg.v17.i31.3575] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 08/12/2010] [Accepted: 08/19/2010] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is currently widely accepted as a standard treatment option for early gastrointestinal neoplasms in Korea. However, ESD has technical difficulties and a longer procedure time than conventional endoscopic resection. So it may have a higher risk of complications than conventional endoscopic resection techniques. We, the ESD study group of Korean Society of Gastrointestinal Endoscopy, have experienced many complications, mostly treated by endoscopic or conservative management. Here, we introduce and share our experiences for management of post ESD complications and review published papers on the topic.
Collapse
|
41
|
Kirschniak A, Subotova N, Zieker D, Königsrainer A, Kratt T. The Over-The-Scope Clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc 2011; 25:2901-5. [DOI: 10.1007/s00464-011-1640-2] [Citation(s) in RCA: 193] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 02/14/2011] [Indexed: 12/13/2022]
|
42
|
Song HJ, Jang SJ, Yun SC, Park YS, Kim MJ, Lee SM, Choi KD, Lee GH, Jung HY, Kim JH. Low Levels of Pepsinogen I and Pepsinogen I/II Ratio are Valuable Serologic Markers for Predicting Extensive Gastric Corpus Atrophy in Patients Undergoing Endoscopic Mucosectomy. Gut Liver 2010; 4:475-80. [PMID: 21253295 DOI: 10.5009/gnl.2010.4.4.475] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 04/27/2010] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS The levels of pepsinogen (PG) I and the PGI/II ratio are useful serologic markers for chronic atrophic gastritis. This study evaluated the performance and clinical implications of these markers in patients undergoing endoscopic mucosectomy. METHODS We enrolled 142 consecutive patients with early gastric tumors and Helicobacter pylori infection who were eligible for mucosectomy. Chronic gastritis and atrophy were assessed using four defined biopsy procedures. Serum PGs were measured by an enzyme immunoassay. Optimal diagnostic cut-offs and performance were determined using receiver operating characteristic curves. RESULTS The PGI level and the PGI/II ratio decreased with corpus-dominant gastritis and as atrophy advanced toward the corpus greater curvature (GC). For the presence of corpus GC atrophy, the areas under the PGI and PGI/II-ratio curves were 0.82 and 0.77, respectively. The optimal cut-off levels were 59.3µg/L for PGI (sensitivity, 83.3%; specificity, 78.4%) and 3.6µg/L for PGI/II ratio (sensitivity, 70.0%; specificity, 78.4%). Using these serologic cut-off levels, we found that the frequency of corpus tumor location differed significantly (32.9% vs 11.1% for PGI <59.3 and ≥59.3µg/L, respectively; and 31.1% vs 14.8% for PGI/II ratio <3.5 and ≥3.5, respectively; p<0.05). CONCLUSIONS A low PGI level and PGI/II ratio are valuable serologic markers for predicting corpus GC atrophy, and have clinical implications with respect to the corpus location of tumors in mucosectomy patients.
Collapse
Affiliation(s)
- Ho June Song
- Asan Digestive Disease Research Institute, Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Liu M. Recent advances in endoscopic therapy for diagnostic and therapeutic endoscopy-associated perforations of the digestive tract. Shijie Huaren Xiaohua Zazhi 2009; 17:3123-3127. [DOI: 10.11569/wcjd.v17.i30.3123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
As diagnostic and therapeutic endoscopy is more widely applied in clinical practice, endoscopy-associated perforations of the digestive tract have become more and more common. Among patients with endoscopy-associated perforations, few can be cured by conservative therapy, and the majority need to undergo laparoscopic or surgical operations to avoid serious consequences. However, the development of new medical instruments makes it possible to effectively and promptly manage endoscopy-related perforations via endoscopic suturing and closure.
Collapse
|
44
|
Endoscopic clips: past, present and future. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:158-60. [PMID: 19319378 DOI: 10.1155/2009/515937] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|