The Usefulness of Surgical Titanium Microclips for Mucosal Repair in the Frontal Sinus Using ORBEYE: A Technical Note

Bifrontal craniotomy frequently involves opening the frontal sinus and mucosal injury. We report a new technique for mucosal repair in the frontal sinus using surgical titanium microclips. Six consecutive patients who underwent bifrontal craniotomy with frontal sinus exposure and mucosal injury underwent mucosal repair using surgical titanium microclips between April 2019 and August 2022. In all cases, the frontal sinus mucosa was peeled from the inner walls of the frontal sinus to ensure sufficient mucosal margin for clipping using ORBEYE. The repair was accomplished with the microclips in all cases. We also sealed the mucosal wound using fibrin glue and sufficiently filled the frontal sinus with bone debris, resulting in zero incidence of postoperative liquorrhea in all cases. Repairing the mucosa using surgical titanium microclips using ORBEYE may be a simple and quick technique when the frontal sinus mucosa is injured during craniotomy.

Application of single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures in total laparoscopic pancreaticoduodenectomy

INTRODUCTION

To investigate the application potential of single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures ("1 + 2" PJ) in total laparoscopic pancreaticoduodenectomy (TLPD). Explore the advantages of "1 + 2" PJ over the traditional double-layer interrupted duct-to-mucosa pancreaticojejunostomy (traditional PJ).

METHODS

We retrospectively collected the clinical data of 184 patients who were admitted in our department from Oct 2019 to Oct 2022, including 95 cases who underwent TLPD with "1 + 2" PJ and 89 cases who underwent TLPD with traditional PJ. The pre/intra/postoperation data were analyzed and compared.

RESULTS

The "1 + 2" PJ procedures were successfully performed in all the 95 cases. When compared with the traditional PJ group, there were no statistically significant variations between the pre-operative and pathological data. However, the "1 + 2" PJ group had a shorter operation time (235 (210, 300) minutes vs. 310 (270, 360) minutes in the traditional PJ group, P < 0.001), shorter pancreaticojejunostomy time (15 (10, 20) minutes vs. 50 (45, 55) minutes in the traditional PJ group, P < 0.001), lower pancreatic fistula (both grade B/C) rate (4.21% vs. 12.34% in the traditional group, P = 0.044), and abdominal infection rate (2.11% vs. 8.99% in the traditional group, P = 0.044), as well as reduced hospital stay (11 (9, 15) days vs. 13 (11, 15) days in the traditional PJ group, P = 0.013). In the "1 + 2" PJ group, the median diameter of the pancreatic duct was 3 (3, 4) mm; 82 cases (86.31%) had a normal pancreatic texture, while nine (9.47%) cases had a hard texture, and seven (7.37%) cases had a soft texture; the median intraoperative blood loss was 200 (100, 400) mL and 19 cases (20.00%) needed intraoperative transfusion; eight cases (8.4%) developed postoperative complications, including four cases (4.2%) of pancreatic fistula (including both grade B/C), one case (1.1%) of bile leakage, three cases (3.2%) of delayed gastric emptying, three cases (3.2%) of postoperative hemorrhage, two cases (2.1%) of abdominal infection, and one case (1.1%) of reoperation; the median hospital stay was 13 (8, 17) days; 25 cases were pathologically classified as pancreatic cancer, 35 cases as bile duct cancer, 23 cases as duodenal cancer, and 12 cases as ampullary cancer.

CONCLUSION

Single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures is a feasible and safe procedure that can be applied in TLPD.

Complete Circumferential Endoscopic Submucosal Dissection for Esophageal Cancer Leaving an Island of Normal Mucosa

Esophageal stricture caused by complete circumferential endoscopic submucosal dissection (ESD) of extensive esophageal squamous cell carcinoma (ESCC) is a major concern and can result in a low quality of life. Normal mucosa may remain within a complete circumferential lesion of ESCC in some cases. We herein report a case of ESCC in which a complete circumferential lesion was treated with ESD while leaving an island of normal mucosa within it. This case demonstrates that preserving areas of normal mucosa within lesions during complete circumferential ESD is not technically difficult and may be an effective measure for preventing esophageal stricture.

Clinical Outcomes of Follow-Up Observation After Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma Invading the Muscularis Mucosa Without Lymphovascular Involvement

BACKGROUND

The therapeutic approach after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) diagnosed as pathological T1a-muscularis mucosa (pT1a-MM) without lymphovascular involvement (LVI) remains uncertain. We aimed to determine whether observation after ESD is acceptable for patients without LVI showing pT1a-MM cancer.

METHODS

We retrospectively registered 566 ESCC patients who were treated with ESD at ten institutions between January 2007 and December 2015. Of those, 447 cases showing pT1a-epithelium/lamina propria mucosa (EP/LPM) without LVI and vertical margin (VM) (EP/LPM group), and 41 cases showing pT1a-MM without LVI and VM (MM group) were analyzed in this investigation. The clinical outcomes were assessed between the groups.

RESULTS

The 5 year cumulative incidence of metastatic recurrence was 0.5% and 3.3% in the EP/LPM and MM groups, respectively (P = 0.121). Two cases showing pT1a-EP/LPM and one showing pT1a-MM experienced lymph node recurrence. The 5 year cumulative incidence of local recurrence was 1.5% and 3.8% in the EP/LPM and MM groups, respectively (P = 0.455). The 5 year disease-specific survival (DSS) rate was 99.3% and 96.6% in the EP/LPM and MM groups, respectively (P = 0.118), whereas the 5 year overall survival rate was significantly higher in the EP/LPM group than in the MM group (92.6% versus 81.1%, respectively; P = 0.021).

CONCLUSIONS

As regards metastatic recurrence and DSS, ESCC patients with pT1a-MM without LVI showed favorable outcomes that were equivalent to those with pT1a-EP/LPM, even when they were not treated with additional therapy after ESD.

Novel Non-duct-to-Mucosa Pancreaticojejunostomy Reconstruction After Pancreaticoduodenectomy: Focus on the Occurrence of Post-pancreatectomy Hemorrhage and Intra-abdominal Abscess

BACKGROUND

Postoperative pancreatic fistulas (POPFs) are considered inevitable in some patients after pancreaticoduodenectomy (PD), and measures to minimize their clinical impact are needed. Postpancreatectomy hemorrhage (PPH) and intra-abdominal abscess (IAA) are the most severe POPF-related complications, and concomitant leakage of contaminated intestinal content is considered the main cause. An innovative method, modified non-duct-to-mucosa pancreaticojejunostomy (TPJ), was created to prevent concomitant leakage of intestinal content, and its effectiveness was compared between two periods.

METHODS

All PD patients undergoing pancreaticojejunostomy from 2012 to 2021 were included. The TPJ group consisted of 529 patients recruited from January 2018 to December 2021. A total of 535 patients receiving the conventional method (CPJ) from January 2012 to June 2017 were used as a control group. PPH and POPF were defined according to the International Study Group of Pancreatic Surgery definition, but only PPH grade C was included for analysis. An IAA was defined as a collection of postoperative fluid managed by CT-guided drainage with documental culture.

RESULTS

There were no significant differences in the rate of POPF between the two groups (46.0% vs. 44.8%; p = 0.700). Furthermore, the percentages of bile in the drainage fluid in the TPJ and CPJ groups were 2.3% and 9.2%, respectively (p < 0.001). Lower proportions of PPH (0.9% vs. 6.5%; p < 0.001) and IAA (5.7% vs. 10.8%; p < 0.001) were observed for TPJ than for CPJ. On adjusted models, TPJ was significantly associated with a lower rate of PPH (odds ratio [OR] 0.132, 95% confidence interval [CI] 0.051-0.343; p < 0.001) and IAA (OR 0.514, 95% CI 0.349-0.758; p = 0.001) than CPJ.

CONCLUSIONS

TPJ is feasible to be performed and is associated with a similar rate of POPF but a lower percentage of concomitant bile in the drainage fluid and subsequent rates of PPH and IAA than CPJ.

Curative Management After Endoscopic Resection for Esophageal Squamous Cell Carcinoma Invading Muscularis Mucosa or Shallow Submucosal Layer-Multicenter Real-World Survey in Japan

INTRODUCTION

Curative management after endoscopic resection (ER) for esophageal squamous cell carcinoma (ESCC), which invades the muscularis mucosa (pMM-ESCC) or shallow submucosal layer (pSM1-ESCC), has been controversial.

METHODS

We identified patients with pMM-ESCC and pSM1-ESCC treated by ER. Outcomes were the predictive factors for regional lymph node and distant recurrence, and survival data were based on the depth of invasion, lymphovascular invasion (LVI), and additional treatment immediately after ER.

RESULTS

A total of 992 patients with pMM-ESCC (n = 749) and pSM1-ESCC (n = 243) were registered. According to the multivariate Cox proportional hazards analysis, pSM1-ESCC (hazard ratio = 1.88, 95% confidence interval 1.15-3.07, P = 0.012) and LVI (hazard ratio = 6.92, 95% confidence interval 4.09-11.7, P < 0.0001) were associated with a risk of regional lymph node and distant recurrence. In the median follow-up period of 58.6 months (range 1-233), among patients with risk factors (pMM-ESCC with LVI or pSM1-ESCC), the 5-year overall survival rates, relapse-free survival rates, and cause-specific survival rates of patients with additional treatment were significantly better than those of patients without additional treatment; 85.4% vs 61.5% ( P < 0.0001), 80.5% vs 53.3% ( P < 0.0001), and 98.5% vs 93.1% ( P = 0.004), respectively. There was no difference in survival rate between the chemoradiotherapy and surgery groups.

DISCUSSION

pSM1 and LVI were risk factors for metastasis after ER for ESCC. To improve the survival, additional treatment immediately after ER, such as chemoradiotherapy or surgery, is effective in patients with these risk factors.

Endoscopic mucosal ischemic index for predicting anastomotic complications after esophagectomy: a prospective cohort study

BACKGROUND

Postoperative complications related to gastric conduit reconstruction are still common issues after McKeown esophagectomy. A novel endoscopic mucosal ischemic index is desired to predict anastomotic complications after McKeown esophagectomy.

AIMS AND METHODS

The purpose of this study was to prospectively evaluate the safety and efficacy of endoscopic examinations of the anastomotic region in the acute period after esophagectomy. Endoscopic examinations were performed on postoperative days (PODs) 1 and 8. The severity of ischemia was prospectively validated according to the endoscopic mucosal ischemic index (EMII).

RESULTS

A total of 58 patients were included after evaluating the safety and feasibility of the endoscopic examination on POD 1 in 10 patients. Anastomotic leakage occurred in 6 patients. Stricture occurred in 13 patients. A greater than 67% circumference and lesion length greater than 20 mm of anastomotic ischemic area (AIA) on POD 1 were associated with developing anastomotic leakage after esophagectomy (OR: 14.5; 95% CI: 1.8-306.5; P = 0.03, OR: 19.4; 95% CI: 1.7-536.8; P = 0.03). More than 67% circumferential ischemic mucosa and ischemic mucosal lengths greater than 20 mm of AIA on POD 1 were associated with developing anastomotic strictures after esophagectomy (OR: 6.4; 95% CI: 1.4-31.7; P = 0.02, OR: 5.9; 95% CI: 1.2-33.1; P = 0.03). Patients with either more than 67% circumferential ischemic mucosa or ischemic mucosal lengths greater than 20 mm of AIA on POD 1 were defined as EMII-positive patients. The sensitivity, specificity, and positive and negative predictive values of EMII positivity on POD 1 for leakage were 100%, 78.8%, 35.3%, and 100%, respectively. The sensitivity, specificity, and positive and negative predictive values of the EMII positivity on POD 1 for strictures were 69.2%, 82.2%, 52.9%, and 90.2%, respectively.

CONCLUSIONS

The application of an endoscopic classification system to mucosal ischemia after McKeown esophagectomy is both appropriate and satisfactory in predicting anastomotic complications.

TRIAL REGISTRATION

Clinical Trial.gov Registry, ID: NCT02937389, Registration date: Oct 17, 2015.

Injectable Thermogel Generated by the "Block Blend" Strategy as a Biomaterial for Endoscopic Submucosal Dissection

Endoscopic submucosal dissection is an established method for the removal of early cancers and large lesions from the gastrointestinal tract but is faced with the risk of perforation. To decrease this risk, a submucosal fluid cushion (SFC) is needed clinically by submucosal injection of saline and so on to lift and separate the lesion from the muscular layer. Some materials have been tried as the SFC so far with disadvantages. Here, we proposed a thermogel generated by the "block blend" strategy as an SFC. This system was composed of two amphiphilic block copolymers in water, so it was called a "block blend". We synthesized two non-thermogellable copolymers poly(d,l-lactide-co-glycolide)-b-poly(ethylene glycol)-b-poly(d,l-lactide-co-glycolide) and blended them in water to achieve a sol-gel transition upon heating in both pure water and physiological saline. We explored the internal structure of the resultant thermogel with transmission electron microscopy, three-dimensional light scattering, ¹³C NMR, fluorescence resonance energy transfer, and rheological measurements, which indicated a percolated micelle network. The biosafety of the synthesized copolymer was preliminarily confirmed in vitro. The main necessary functions as an SFC, namely, injectability of a sol and the maintained mucosal elevation as a gel after injection, were verified ex vivo. This study has revealed the internal structure of the block blend thermogel and illustrated its potential application as a biomaterial. This work might be stimulating for investigations and applications of intelligent materials with both injectability and thermogellability of tunable phase-transition temperatures.

Evaluation and Pathologic Classification of Choledochal Cysts: Clinicopathologic Analysis of 84 Cases From the West

Choledochal cyst (CC) is believed to be a mostly Asian disorder. As a clinically defined entity, its pathologic correlates are poorly characterized. Eighty-four resected CCs from the West were reanalyzed. After applying established Japanese criteria, 9/66 with available imaging were disqualified and 10/39 with preoperative cyst typing had to be recategorized. None had been diagnosed with, or evaluated for, pancreatobiliary maljunction, but on retrospective analysis of radiologic images, 12/66 were found to have pancreatobiliary maljunction. The clinical findings were: F/M=5.7; mean age, 48; most (77%) presented with abdominal pain; mean size, 2.9 cm; choledocholithiasis 11%. Gross/histologic examination revealed 3 distinct pathology-based categories: (I) Cystic dilatation of native ducts (81%). (II) Double bile duct (13%), almost all of which were found in women (10/11); all were diagnosed by pathologic examination, and not preoperative diagnosis. (III) Gastrointestinal (GI) duplication type (6%). Microscopic findings of the entire cohort included mucosal-predominant lymphoplasmacytic inflammation (50%), follicular cholangitis (7%), mucosal hyperplasia (43%; 13% with papillae), intestinal metaplasia (10%), BilIN-like hyperplasia (17%), erosion/ulceration (13%), and severe dysplasia-mimicking atypia including "detachment atypia" and micropapillary degeneration (11%). Carcinomatous changes were seen in 14 cases (17%) (high-grade dysplasia/carcinoma in situ in 7, intraductal papillary neoplasm 1, and invasive carcinoma 6); and 13/14 of these occurred in pathologic category I, all with cyst size >1 cm. In conclusion, diagnostic imaging guidelines used in Asia are not routinely used (but should be adopted) in the West. Pathologically, cases designated as CC are classifiable in 3 groups: category 1 (dilated native duct type), more prone to carcinomatous change; category 2, double-duct phenomenon (all but 1 being female in this study); and category 3, GI-type duplication. Overall, 17% of CCs show carcinomatous change (50% of them invasive). CC specimens should be carefully examined with this classification and submitted entirely for assessment of at-risk mucosa and cancerous transformation.

Principles of Intramural Surgery

Intramural surgery is a minimally invasive surgical technique based on flexible endoscopy. The first step involves the initial mucosal incision for entry point. Then a submucosal tunnel is dissected to the site of the target anatomy. The procedure performed may include myotomy or lesion removal. When complete, the initial mucosal incision is closed. This technique separates the mucosal flap from the surgical site, minimizing the risk of full-thickness perforation and gastrointestinal leakage. Peroral endoscopic myotomy is the most studied application of intramural surgery but other procedures have emerged. This article explores principles of intramural surgery and summarizes its applications.

Epidemiological profile of mucosal melanoma in Brazil

Mucosal melanomas are primary malignant neoplasias originated from melanocytes within mucous membranes in any part of mucosal surface lining, more commonly, in the nasal cavity and accessory sinuses, oral cavity, lips, pharynx, vulvar, vaginal, cervix and anorectal mucosa. Epidemiology data regarding mucosal melanomas in Brazil is scarce, hence the motivation to conduct this research paper. The χ2 test was used to compare categorical variables. Forward stepwise logistic regression method was used in the multivariate analysis to identify independent predictors of early death. A total of 801 patients were included in the analysis. Surgical resection is frequently the first approach to primary tumours (65.3%), even though the utility of lymph node surgery and radiation therapy is not well established. Advanced stage was observed in more than two thirds of patients. Early death was observed in 28.3%. MM cases with regional or distant metastases as well as those located in unusual locations had almost 4 times more risk for early death. Besides that, MM located in lips, oral cavity and pharynx and those receiving chemotherapy had 2 times more risk of early death.

Time-varying pattern of recurrence risk for localized melanoma in China

BACKGROUND

Acral and mucosal melanomas are rarely seen in Caucasians but common in China. There are limited data on the recurrence characteristics for these patients. This study aimed to identify the recurrence pattern for localized melanoma in China, especially acral and mucosal subtypes.

METHODS

Patients with localized melanoma who underwent radical resection between January 1999 and December 2014 in southern China were retrospectively reviewed. Survival and annual recurrence hazard were analyzed by Kaplan-Meier method and hazard function, respectively.

RESULTS

Totally, 1012 patients were included (acral melanoma 400; chronic sun-induced damage (CSD)/non-CSD melanoma 314; mucosal melanoma 298). Recurrence was recorded in 808 patients (localized 14.1%; regional 29.6%, and distant 56.3%). Mucosal melanoma had local and M1c stage recurrence more frequently than cutaneous melanoma, but less frequent regional node relapse. There was no difference in recurrent site distribution between acral and CSD/non-CSD melanoma. The annual recurrence hazard curve for the entire cohort showed a double-peaked pattern with the first major peak in the second year after surgery and the second peak near the seventh year. Mucosal melanoma had a higher recurrence risk than cutaneous melanoma. Acral melanoma had a lower flat recurrence peak than CSD/non-CSD melanoma. Tumor thickness > 4.0 mm, ulceration, positive regional nodes, and wound infection were associated with a higher recurrence risk in cutaneous melanoma. Adjuvant therapy reduced the recurrence risk of cutaneous melanoma but not of mucosal melanoma.

CONCLUSIONS

This is a large cohort about the rule of recurrence risk in acral and mucosal melanoma and will provide an initial framework for development of surveillance and adjuvant strategy for Chinese melanoma patients.

[Endoscopic minimally invasive treatment--from inside the lumen to outside the lumen, from the superficial layer to the deep layer]

Since the introduction of endoscopic submucosal dissection (ESD) in China in 2006, endoscopic minimally invasive treatment has experienced a booming development for more than 10 years, and its indications are gradually being expanded from inside the lumen to outside the lumen, from the superficial layer to the deep layer, from organic diseases to functional diseases. This article summaries the development of endoscopic minimally invasive resection in the past 10 years, from the perspective of mucosa, submucosa, muscularis, serosal and even extraluminal lesions, respectively, to introduce the role of endoscopic minimally invasive treatment. For mucosal lesions, ESD has become a first-line treatment for early gastric cancer; endoscopic treatment of colorectal lesions is still controversial in Europe and the United States, but is gradually being accepted. For submucosal tumors(SMT), the Expert Consensus for Endoscopic Diagnosis and Treatment of Submucosal Tumors in China (version 2018) was published in 2018, and the principles and related technical rules for gastrointestinal SMT have been highlighted. For serosal and even extraluminal lesions, natural orifice transluminal endoscopic surgery (NOTES) and tunnel endoscopic surgery, mainly including endoscopic myotomy (POEM) and endoscopic transmucosal tunneling tumor resection (STER), showed potential for development in preliminary studies, and showed good results in cholecystectomy, appendectomy, achalasia, gastroparesis and even extra-gastrointestinal tumor resection. This article describes the various endoscopic treatment techniques, and looks into their application prospects and future challenges.

Novel Minimally Invasive Technique of Neovaginoplasty Using an Absorbable Adhesion Barrier

Our objective was to provide a minimally invasive neovaginoplasty technique to construct a nearly physiologic vagina to facilitate sexual functioning and appropriate vaginal length in patients with congenital vaginal agenesis. This retrospective study at a tertiary care hospital comprised 52 patients with congenital vaginal agenesis because of Mayer-Rokitansky-Küster-Hauser syndrome or androgen insensitivity syndrome presented for vaginal reconstruction. Modified McIndoe vaginoplasty was done in all patients between 2010 and 2018 using a vaginal mold created with glove, nonadherent petroleum gauze, and Interceed absorbable adhesion barrier (Ethicon, Johnson & Johnson, Somerville, NJ) that was placed in the neovagina space created between the bladder and rectum for 7 days. Operative details, complications, length and width of the neovagina, and functional outcome were evaluated. The mean operation time was 35 minutes. The mean length of the constructed neovagina was 8.4 cm × 3.4 cm at 6 weeks follow-up. Epithelialization was completed by 4 to 6 months. All patients reported satisfactory sexual activity with no pain and good mucosal sensitivity. This modified neovaginoplasty technique is easy to perform, involves painless postoperative dilatations as the cornerstone of treatment, and results in adequate secretion, allowing lubrication and acceptable physiologic results.

Initial Assessment of Mucosal Capture and Leak Pressure After Gastrointestinal Stapling in a Porcine Model

BACKGROUND

Anastomotic leak is a leading cause of morbidity and mortality in gastrointestinal surgery. The serosal aspect of staple lines is commonly observed for integrity, but the mucosal surface and state of mucosa after firing is less often inspected. We sought to assess the degree of mucosal capture when using stapling devices and determine whether incomplete capture influences staple line integrity.

METHODS

Porcine ileum was transected in vivo and staple lines were collected and rated for degree of mucosal capture on a 5-point scale from 1 (mucosa mainly captured on both sides) to 5 (majority of mucosa not captured). Mucosal capture was also assessed in ex vivo staple lines, and fluid leakage pressure and location of first leak was assessed. Stapling devices studied were Echelon Flex GST with 60-mm blue (GST60B) and green (GST60G) cartridges, and Medtronic EndoGIA Universal with Tri-Staple Technology™ with 60 mm medium (EGIA60AMT) reloads (purple).

RESULTS

GST60B and GST60G staple lines produced significantly better mucosal capture scores than the EGIA60AMT staple lines (p < 0.001, in all tests). Compared to EGIA60AMT, leak pressures were 39% higher for GST60B (p < 0.001) and 23% higher for GST60G (p = 0.022). Initial staple line leak site was associated with incomplete mucosal capture 78% of the time.

CONCLUSIONS

There are differences in degree of mucosal capture between commercial staplers, and the devices that produce better mucosal capture had significantly higher leak pressures. Further research is needed to determine the significance of these findings on staple line healing throughout the postoperative period.

Endoscopic submucosal dissection in a patient with esophageal adenoid cystic carcinoma

We report the first use of endoscopic submucosal dissection (ESD) for the treatment of a patient with adenoid cystic carcinoma of the esophagus (EACC). An 82-year-old woman visited our hospital for evaluation of an esophageal submucosal tumor. Endoscopic examination showed a submucosal tumor in the middle third of the esophagus. The lesion partially stained with Lugol’s solution, and narrow band imaging with magnification showed intrapapillary capillary loops with mild dilatation and a divergence of caliber in the center of the lesion. Endoscopic ultrasound imaging revealed a solid 8 mm × 4.2 mm tumor, primarily involving the second and third layers of the esophagus. A preoperative biopsy was non-diagnostic. ESD was performed to resect the lesion, an 8 mm submucosal tumor. Immunohistologically, tumor cells differentiating into ductal epithelium and myoepithelium were observed, and the tissue type was adenoid cystic carcinoma. There was no evidence of esophageal wall, vertical stump or horizontal margin invasion with pT1b-SM2 staining (1800 μm from the muscularis mucosa). Further studies are needed to assess the use of ESD for the treatment of patients with EACC.

Sinus Floor Elevation Using the Lateral Approach and Bone Window Repositioning I: Clinical and Radiographic Results in 102 Consecutively Treated Patients Followed from 1 to 5 Years

PURPOSE

To determine the potential complications and clinical outcomes using the lateral sinus elevation technique with window repositioning.

MATERIALS AND METHODS

One hundred nine sinus elevations were performed on 102 consecutively treated patients. Following lateral window outward fracturing, sinus mucosa was elevated, and the sinus was grafted with anorganic bovine bone. Two hundred five implants were placed: 160 concomitantly with grafting, and 45 six months after grafting. Seventeen implants replaced single missing molars. One hundred eighty-eight implants replaced multiple missing posterior teeth. The bone window was repositioned over the osteotomy site and the flap sutured. Implants were connected at 6 months and followed up from 12 to 60 months (mean: 29.8 months). In 30 cases, biopsy specimens were harvested from the lateral wall of the sinus for histomorphometric analysis. The Fisher exact test and Kruskal-Wallis test followed by the Mann-Whitney test were used for statistical analysis.

RESULTS

No clinically significant complications were encountered in using this technique (mucosa tear, intraoperative bleeding, window sequestration). In three cases, the window was separated in two before outfracturing. In 20 cases, it was stabilized with a collagen fleece. Limited sinus mucosa tears occurred in 14 cases during elevation. They were patched with a collagen membrane, and 18 implants were placed in these cases. All of the latter cases osseointegrated at abutment connection with no statistically significant difference in the outcome compared with implants placed with no tear of the membrane (P < .05). The reconstruction of the lateral wall was confirmed in all cases. No significant differences in outcomes were found between the immediately and delayed placed implants (P < .05). One implant failed in the immediately placed group due to a sinus infection. All other implants were loaded and remained in function during the observation period.

CONCLUSION

Lateral sinus elevation with window repositioning is safe and effective with minimal risks, such as mucosal tear, intraoperative bleeding, or window sequestration. The repositioned window can serve as an alternative for collagen membrane in containing the graft. Graft maturation, percent of vital bone formation, and the potential of the window to serve as a source of osteogenic cells need to be confirmed histomorphometrically. This will be reported in a subsequent article.

Feasibility of endoscopic submucosal dissection for upper gastrointestinal submucosal tumors treatment and value of endoscopic ultrasonography in pre-operation assess and post-operation follow-up: a prospective study of 224 cases in a single medical center

BACKGROUND AND AIMS

Diagram, diagnosis, and treatment with endoscopic submucosal dissection (ESD) for upper gastrointestinal submucosal tumors (SMTs) remain controversial, although endoscopic ultrasonography (EUS) and ESD have been established in diagnosis and treatment of SMTs in decades, respectively. In this study, we have investigated prospectively the profile of upper gastrointestinal SMTs, assessed the effect and feasibility of ESD in upper gastrointestinal SMTs treatment, as well as value of EUS in pre-ESD diagnosis and post-ESD follow-up for gastrointestinal SMTs.

METHODS

The upper gastrointestinal SMTs patients detected with endoscopy were further checked by EUS, then received series ESD treatment, and fulfilled 3- and 12-month follow-up EUS detection between July 2011 and March 2015. The parameters of SMTs with EUS examination (size, original layer) and treatment with ESD (en bloc resection rate, procedure time, procedure-related complications) were investigated and analyzed.

RESULTS

A total number of 224 patients with upper gastrointestinal SMTs were enrolled, and 108 (48.2 %) were men. The mean age was 50.4 ± 12.0 years (range 19-77 years). In total, 92 (41.1 %), 14 (6.3 %), 61 (27.2 %), 22 (9.8 %), 25 (11.2 %), and 10 (4.5 %) SMTs were located in esophagus, cardiac, fundus, body and antrum of stomach, duodenum, respectively. Two hundred and eight (92.9 %) patients were successfully treated with an en bloc ESD, while other 16 patients (7.1 %) suffered ESD failure (5.3 %, 12 case) or severe complications (1.8 %, 4 cases). The mean procedure time of ESD was 47.4 ± 27.3 min (range 10-180 min). The mean size of the SMTs measured with ESD samples was 13.6 ± 9.5 mm (range 4-113 mm). In total, 87 (38.8 %), 23 (10.3 %), and 114 (50.9 %) tumors originated from muscularis mucosa, submucosa, and muscularis propria, respectively. The majority of SMTs were leiomyoma (109, 48.7 %) and gastrointestinal stromal tumors (GIST) (77, 34.4 %), while other SMTs were confirmed as ectopic pancreas (21, 9.4 %), adenoid tumor (8, 3.6 %), lipoma (5, 2.2 %), neuroendocrine tumor (3, 1.3 %), and granulosa cell tumor (1, 0.4 %). The accuracy rate of EUS in pathological diagnosis or original layer was 82.6 % (185/224) or 74.6 % (167/224). Residual tumors were detected with EUS in 3 patients (1.3 %) in 3-month follow-up and no recurrence during 12-month follow-up period.

CONCLUSIONS

The predominant SMTs in upper gastrointestinal tract were leiomyoma in esophageal tumors which originated from muscularis mucosae and GIST in stomach which originated from muscularis propria detected satisfactorily with EUS. This study showed that ESD was a safe and effective treatment for upper gastrointestinal SMTs.

Inter-Observer Variability in the Interpretation of Endoscopic Mucosal Resection Specimens of Esophageal Adenocarcinoma: Interpretation of ER specimens

INTRODUCTION

Endoscopic resection (ER) has revolutionized the staging and therapy of superficial esophageal adenocarcinoma. Pathologic evaluation allows an assessment of the risk of lymph node metastases based on tumor characteristics. The aim of this study was to assess the inter-observer variability in pathologic assessment of ER specimens of esophageal adenocarcinoma.

METHODS

We performed a retrospective study on ER specimens of superficial esophageal adenocarcinoma from four US institutions. Original endoscopic resection slides were re-reviewed by two blinded, experienced (study) gastrointestinal pathologists for the depth of tumor invasion, tumor grade, and the presence of lymphovascular invasion (LVI). Discordance was considered present only when both study pathologists disagreed with the original report.

RESULTS

There were 25 ER specimens reviewed for this study, and discordance occurred in 12 of the 25 specimens (48%) for the depth of tumor invasion. In most cases (83%), the discordance was related to overstaging a true T1a lesion. We found that only 38% of true T1a lesions were correctly staged for depth of invasion. Less commonly discordance was secondary to understaging a true T1b lesion. There was concordance between the two study pathologists in 22/25 cases (88%) on the depth of invasion. Discordance was present for tumor grade in 8/18 cases (44%) and for LVI in 4/16 cases (25%). Concordance between the study pathologists was 80% for tumor grade and 88% for LVI.

CONCLUSIONS

There was an alarmingly high rate of discordance (48%) between the study pathologists and the original pathology assessment for the depth of tumor invasion in ER specimens. This was particularly common for lesions called T1b on the original pathology report. Since critical decisions are made regarding esophageal preservation or esophagectomy on the basis of the pathologic interpretations of ER specimens, it behooves surgeons to understand the inter-observer variability. Review of ER specimens by an experienced GI pathologist is recommended to ensure that patients receive the appropriate treatment for superficial esophageal adenocarcinoma.

[The clinical observation of the repair of pharyngeal mucosa and neck skin defects with acellular dermal matrix]

OBJECTIVE

To evaluate the clinical effect of acellular dermal matrix (ADM) on the repair of different tissue defects in pharyngeal and laryngeal cancer.

METHOD

Twenty-three cases of pharyngeal and laryngeal cancer were analyzed retrospectively, including 16 patients with pharyngeal cancer, and 7 patients with laryngeal cancer. After surgery, the patients appeared two types of tissue defects respectively: hypopharynx tissue defect and neck skin tissue defect. These defects were repaired with ADM, and the clinical effects were observed.

RESULT

Sixteen cases of hypopharynx tissue defect and 7 cases of neck skin tissue defect were repaired with ADM. One case in hypopharynx tissue defect group and 2 cases in neck skin tissue defect group undergone pharyngeal fistula postoperatively.

CONCLUSION

The repair of tissue defects in pharyngeal and laryngeal cancer with ADM had some advantages, such as good histocompatibility, low immune rejection, wide material sources and simple method. There were some differences in clinical effects between hypopharynx cavity defect and neck skin tissue defects, so the emphasis of the need to pay attention to is different in the clinical.

Steroid Administration is Effective to Prevent Strictures After Endoscopic Esophageal Submucosal Dissection: A Network Meta-Analysis

Esophageal stricture is a severe adverse event after circumferential endoscopic submucosal dissection (ESD). Steroid administration is a new method to prevent stricture formation. We performed a meta-analysis to investigate the efficacy and safety of steroid administration to prevent esophageal stricture after circumferential ESD. PubMed, the Cochrane Library, EMBASE, Chinese Biomedical Database, and Clinicaltrials.gov were searched. Studies on steroid administration + endoscopic balloon dilation (EBD) versus EBD alone for esophageal stricture were included and pooled analyzed in random-effects models. Besides, subgroup analysis and network analysis were performed to define the influence of ESD type and steroid administration method. Twelve studies involving 513 patients were included. Meta-analysis showed that steroid administration significantly achieved a lower stricture rate (risk ratio [RR], 0.40; 95% CI, 0.20-0.81) and less required EBD sessions (mean difference [MD], -4.33; 95% CI, -6.10 to -2.57) than control. Subgroup analysis indicated that steroid was effective after both semi- and complete circumferential ESD. Network meta-analysis showed that compared with oral steroid, local injected steroid had a similar effect to prevent stricture (RR, 1.16; 95% CI, 0.48-2.85), whereas a better effect to reduce required EBD sessions (MD, 7.77; 95%CI, 0.26-15.3). Additional steroid administration is effective to reduce the stricture rate and required EBD sessions. And local injected steroid was superior to oral steroid in EBD reduction, whereas due to the varied method and dose of steroid administration, the finding needs to be clarified in the future.

Radiofrequency ablation for Barrett's-associated intramucosal carcinoma: a multi-center follow-up study

BACKGROUND

Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett's esophagus. Its durability in eradicating Barrett's-associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC.

METHODS

Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy-proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and for IMC and associated dysplasia. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC/dysplasia. Our secondary outcome of interest was treatment-related complications.

RESULTS

36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett's length of 3.5 ± 2.5 cm, underwent RFA for biopsy-proven IMC. EMR was performed in 31 (86%) prior to or during RFA. Complete eradication of IMC/dysplasia was achieved in 32/36 (89%) and patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC/dysplasia was achieved in 29/36 (81%) patients. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC/dysplasia (p = 0.03). Treatment-related complications included: bleeding (3%) and stricture formation (19%).

CONCLUSION

RFA is an effective and durable treatment option for Barrett's-associated IMC. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up.

Oestrogen receptor alpha expression in neovaginal tissue of women following modified Abbé-McIndoe technique and in premenopausal women

The aim of the study was to compare the expression of oestrogen receptor alpha (ERα) in neovaginal tissue of patients with vaginal agenesis following neovaginoplasty using regenerated, oxidised cellulose in premenopausal women. A prospective, observational case-control study was performed on eight patients with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty and 10 control premenopausal women following benign gynaecologic surgery. 6F11 monoclonal antibody was used to determine ERα expression in the vaginal mucosa. Quantitative and qualitative evaluations were performed, respectively, in vaginal epithelium and stroma. The thickness of the vaginal epithelium was determined as the vertical distance between the basal layer cells and the apical surface of the superficial layer. The percentage of ERα-expressing cells was higher in the control group, except in the superficial zone of the epithelium. In the stromal tissue, ERα was detected in only one patient from the neovagina group compared with nine women in the control group. The neovagina group had a statistically thinner epithelium. Our study suggests that women with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty using regenerated oxidised, cellulose experience relatively local hypo-oestrogenism in the first year after surgery, with repercussion in vaginal trophism.

The effectiveness of endoscopic submucosal dissection followed by chemoradiotherapy for superficial esophageal cancer

BACKGROUND

To evaluate the risks and benefits of endoscopic submucosal dissection (ESD) in addition to chemoradiotherapy (CRT) for the treatment of superficial esophageal squamous cell carcinoma (SESCC).

METHODS AND MATERIALS

We retrospectively reviewed the treatment outcomes of 47 patients with SESCC treated between October 2000 and December 2011. Sixteen patients with invasion into the submucosal layer (T1b) or the muscularis mucosa (m3) with positive vascular invasion were treated with CRT after ESD (ESD-CRT group). The lymph node area was irradiated to a total dose of 40-44 Gy and a boost radiation was administered if PET-positive lymph nodes or positive margins were observed. The remaining 31 patients received definitive CRT only (dCRT group).

RESULTS

The radiation field was significantly larger in the ESD-CRT group; the "long T" was used in 11 patients (35.4%) in the dCRT group and 15 (93.7%) in the ESD-CRT group (p = 0.0001). The total radiation dose was smaller in the ESD-CRT group; 40 Gy was used in 10 patients (62.5%) in the ESD-CRT group and all but one patient in the dCRT group received ≥60 Gy (p = 0.00001). The 3-year overall survival rates in the dCRT and ESD-CRT groups were 63.2% and 90.0% respectively (p = 0.118). Recurrence developed in nine patients (29.0%) in the dCRT group and one (6.3%) in the ESD-CRT group. Local recurrence was observed in six patients (19%) in the dCRT group and none in the ESD-CRT-group (p = 0.029). Pericardial effusion (≥Grade 3) occurred in three patients (9.7%) in the dCRT group and none in the ESD-CRT group.

CONCLUSIONS

ESD followed by CRT is an effective and safe approach for SESCC at m3 or T1b. This combination of ESD and CRT improves the local control rate, and it could decrease the number of cardiac toxicities due to a radiation-dose reduction relative to CRT alone.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic excavation for the treatment of small esophageal subepithelial tumors originating from the muscularis propria

BACKGROUND/AIMS

This study was designed to evaluate the safety and efficacy of endoscopic excavation for esophageal subepithelial tumors originating from the muscularis propria.

METHODOLOGY

Forty-five patients with esophageal subepithelial tumors originating from the muscularis propria were treated with endoscopic excavation between January 2010 and June 2012. The key steps were: (1) making several dots around the tumor; (2) incising the mucosa along with the marker dots, and then seperating the tumor from the muscularis propria by using a hook knife or an insulated-tip knife; (3) closing the artificial ulcer with clips after the tumor was removed.

RESULTS

The mean tumor diameter was 1.1 ± 0.6 cm. Endoscopic excavation was successfully performed in 43 out of 45 cases (95.6%), the other 2 cases were ligated with nylon rope. During the procedure perforation occurred in 4 (8.9%) patients, who recovered after conservative treatment. No massive bleeding or delayed bleeding occurred. Histologic diagnosis was obtained from 43 (95.6%) patients. Pathological diagnoses of these tumors were leiomyomas (38/43) and gastrointestinal stromal tumors (5/43).

CONCLUSIONS

Endoscopic excavation is a safe and effective method for the treatment of small esophageal subepithelial tumors originating from the muscularis propria.

Esophageal mucosal resection versus esophagectomy: a comparative study of surgical results in patients with advanced megaesophagus

BACKGROUND

The surgical treatment of advanced megaesophagus has no consensus, being esophagectomy the more commonly used method. Since it has high morbimortality--inconvenient for benign disease -, in recent years an alternative has been introduced: the esophageal mucosal resection.

AIM

To compare early and late results of the two techniques evaluating the operative time, length of ICU stay; postoperative hospitalization; total hospitalization; intra- and postoperative complication rates; mortality; and long-term results.

METHODS

Were evaluated retrospectively 40 charts, 23 esophagectomies and 17 mucosectomies. In assessing postoperative results, interviews were conducted by using a specific questionnaire.

RESULTS

Comparing the means of esophagectomy and mucosal resection, respectively, the data were: 1) surgical time--310.2 min and 279.7 min (p > 0.05); 2) length of stay in ICU--5 days and 2.53 days (p <0.05); 3) total time of hospitalization--24.25 days and 20.76 days (p> 0.05); 4) length of hospital stay after surgery--19.05 days and 14.94 days (p> 0.05); 5) presence of intraoperative complications--65% and 18% (p <0.05); 6) the presence of postoperative complications - 65% and 35% (p> 0.05). In the assessment of late postoperative score (range 0-10) esophagectomy (n = 5) obtained 8.8 points and 8.8 points also got mucosal resection (n = 5).

CONCLUSIONS

Esophageal mucosal resection proved to be good alternative for surgical treatment of megaesophagus. It was advantageous in the immediate postoperative period by presenting a lower average time in operation, the total hospitalization, ICU staying and complications rate. In the late postoperative period, the result was excellent and good in both operations.

Interest of submucosal dissection knife for endoscopic treatment of Zenker's diverticulum

BACKGROUND

Dual-Knife(®) (Olympus) and Hydride-Knife(®) are new needle knives frequently used for submucosal dissection because of their safety and precision. In this study we aimed to evaluate the efficacy and safety of such devices in the diverticulopexy by flexible endoscopy.

METHODS

From February 2009 to March 2013, 42 patients (25 men), mean age 74.5, with symptomatic Zenker's diverticulum, were included in a non-randomized prospective multicenter study. The symptoms described by all patients include dysphagia, regurgitation and/or swallowing disorders. The diverticulopexy was performed with the Dual-Knife(®) or Hydrid-Knife(®), after septum exposure with the diverticuloscope, and terminated with distal tip clips positioning. All complications were noted. Patients' symptoms were regularly assessed during follow-up visits or telephone interviews.

RESULTS

The first endoscopy treatment was successful for all patients. Thirty-seven patients (88%) had symptoms improvement after the first treatment. The recurrence rate was 14% (6 patients); a second endoscopic treatment was required 12 months on average after the first treatment, with 100% efficiency. Mid-term (16 months) efficiency was 91.67% after 1 to 3 endoscopic treatments. A total of 55 procedures were performed without perforation or significant bleeding and 3 patients underwent surgery. In multivariate analysis, the diverticulum size and the type of dissection knife were not risks factors for recurrence.

CONCLUSIONS

Endoscopic diverticuloscope-assisted diverticulotomy with submucosal dissection knives is a safe and effective alternative treatment for patients with a symptomatic Zenker's diverticulum measuring between 2 and 10 cm.

[Esophagectomy after endoscopic submucosal dissection (ESD)]

Herein, we report 9 patients who underwent esophagectomy after endoscopic submucosal dissection (ESD) between April 2003 and December 2013. All patients were men, with a mean age of 65 years. En bloc ESD was performed, and no complications arose in any patient. The mean surgical time of esophagectomy was 323 minutes, and mean blood loss was 295 mL. Postoperative complications were present in 5 patients(anastomotic leakage in 3, pulmonary complications in 2, and recurrent laryngeal nerve palsy in 1). In a patient diagnosed with pT1b-SM1 disease after ESD, a residual tumor(pT1a-MM, N0) was detected after esophagectomy. In another patient diagnosed with pT1b-SM2 disease, lymph node metastasis was detected after esophagectomy. In all patients, curative resection was performed, and no recurrences have been observed to date. This highlights the importance of additional esophagectomy after ESD for patients with pT1b disease. Esophagectomy after ESD can be considered a valid treatment because it provides high curative rates with acceptable safety.

[Application of the xenogenic acellular dermal matrix membrane application used in the postoperative tissue shortage repair]

OBJECTIVE

To observe the short-term and long-term curative effect of the xenogenic acellular dermal matrix membrane (or joint muscle flap transfer) application used in the 82 cases postoperative tissue shortage repair that after the head neck carcinoma resection.

METHOD

To held the 82 cases head neck carcinoma postoperative mucosa shortage repaired after resection by the xenogenic acellular dermal matrix membrane (or joint muscle flap transfer), 65 cases mucosa shortage wound be directly covered by the repair membrane and the other 17 cases mucosa shortage wound be repaired by the tranfered muscle tissue flap with the repair membrane covered; 53 cases underwent additional postoperative radiotherapy between 2-4 weeks and follow-up in 1, 3, 6, 12, 18, 24, 30, 36, 48, 60 months and observed the operation site repair process through the electronic laryngoscope, observed the patients respiration, swallow, phonation function.

RESULT

Seventy-seven cases patients operation incision reached I phase healing standard, another 5 cases patients operation incision reached II phase healing standard because of the wound infection and fully-recovered through the local wound drainage,dressing process. All the patients tracheal cannula,the stomach tube be extubated successfully and without the local cicatricial constriction occurred. Seventy-eight cases follow up period reached 1 year including 53 cases who underwent postoperative radiotherapy, 49 cases follow up period reached 3 years including 32 cases who underwent postoperative radiotherapy, 14 cases follow up period reached 5 years including 12 cases who underwent postoperative radiotherapy. The patients with static local lesions discovered no reaction such as exclusion, allergy.

CONCLUSION

The application of xenogenic acellular dermal matrix membrane (or joint muscle flap transfer used in in the postoperative tissue shortage repair that after the head neck carcinoma resection have several advantage such as comparatively easily implementation, operation safety edge enough,well preserved organ function, comparatively low incidence about the laryngeal stenosis, the short-term and long-term repair effect are all exact.

The impact of endoscopic ultrasound findings on clinical decision making in Barrett's esophagus with high-grade dysplasia or early esophageal adenocarcinoma

The clinical utility of endoscopic ultrasound (EUS) for staging patients with Barrett's esophagus and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to endoscopic therapy is unclear. We performed a retrospective analysis of patients with HGD or IMC referred to an American medical center for endoscopic treatment between 2004 and 2010. All patients had pretreatment staging by EUS. We examined the frequency that EUS findings consistent with advanced disease (tumor invasion into the submucosa, lymph node involvement, or regional metastasis) led to a change in management. The analysis was stratified by nodularity and pre-EUS histology. We identified one hundred thirty-five patients with HGD (n = 106, 79%) or IMC (n = 29, 21%) had staging by EUS (79 non-nodular, 56 nodular). Pathologic lymph nodes or metastases were not found by EUS. There were no endosonographic abnormalities noted in any patient with non-nodular mucosa (0/79). Abnormal EUS findings were present in 8/56 patients (14%) with nodular neoplasia (five IMC, three HGD). Endoscopic mucosal resection was performed in 44 patients with a nodule, with 13% (6/44) having invasive cancer. In nodular neoplasia, the EUS and endoscopic mucosal resection were abnormal in 24% (5/21) and 40% (6/15) of those with IMC and 9% (3/35) and 0% (0/29) of those with HGD, respectively. In this study we found that EUS did not alter management in patients with non-nodular HGD or IMC. Because the diagnostic utility of EUS in subjects with non-nodular Barrett's esophagus is low, the value of performing endoscopic mucosal resection in this setting is questionable. For patients with nodular neoplasia, resection of the nodule with histological examination had greater utility than staging by EUS.

Lack of usefulness of ureteral reconstruction with free bladder mucosa flap in dogs confirmed by microangiography

BACKGROUND

There is a paucity of data addressing the blood supply in the surgically reconstructed ureter, and complete lack of microangiographic studies of the reconstructed ureter with the use of a free bladder mucosa flap. The present study evaluated the blood supply in the reconstructed dog ureter after a 5-centimeter segment resection, supplemented by a tube constructed from a free bladder mucosa flap.

MATERIAL AND METHODS

Female mongrel dogs (n=29) were used in this study. Under general anaesthesia, a 5-centimeter autologous free bladder mucosa flap was used to construct a tube, which was afterwards grafted to replace a 5-centimeter ureter resection. After a period of 3 months (n=2) and after 1 year (n=2), microangiography was performed to assess the revascularization of the grafted ureter.

RESULTS

In our study, we observed the continuity of the ureter, but the grafted reconstruction was narrowed by the cicatrization in about 86% (n=25) of cases. This resulted in the development of hydronephrosis, as described in previous publications. The ureteral wall was covered by a normal urothelium, but consisted of fibrous connective tissue, which failed to restore a regular (normal) coat. The reconstructed segment showed no smooth muscle cells. A few smooth monocytes were found only at the border with intact portions of the ureter. The microangiography performed at the end of the experiments showed no vascularization of the restored segment of the ureter.

CONCLUSIONS

The experiments showed a whole regeneration of urothelium in the transected and reanastomosed ureters. However, there was no regeneration of the muscular coat and a complete lack of revascularization.

Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy

PURPOSE

The purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy.

METHODS

Eight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM.

RESULTS

Demographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p = 0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p < 0.05).

CONCLUSION

POEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.

Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer

AIM: To investigate the effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in treating superficial esophageal cancer (SEC).

METHODS: Studies investigating the safety and efficacy of ESD and EMR for SEC were searched from the databases of Pubmed, Web of Science, EMBASE and the Cochrane Library. Primary end points included the en bloc resection rate and the curative resection rate. Secondary end points included operative time, rates of perforation, postoperative esophageal stricture, bleeding and local recurrence. The random-effect model and the fixed-effect model were used for statistical analysis.

RESULTS: Eight studies were identified and included in the meta-analysis. As shown by the pooled analysis, ESD had significantly higher en bloc and curative resection rates than EMR. Local recurrence rate in the ESD group was remarkably lower than that in the EMR group. However, operative time and perforation rate for ESD were significantly higher than those for EMR. As for the rate of postoperative esophageal stricture and procedure-related bleeding, no significant difference was found between the two techniques.

CONCLUSION: ESD seems superior to EMR in the treatment of SEC as evidenced by significantly higher en bloc and curative resection rates and by obviously lower local recurrence rate.

[Comparison of endoscopic submucosal tunnel dissection with endoscopic submucosal dissection for large esophageal superficial neoplasms]

OBJECTIVE

To compare the safety and efficiency of endoscopic submucosal tunnel dissection (ESTD) and endoscopic submucosal dissection (ESD) for large esophageal superficial neoplasms.

METHODS

A total of 235 consecutive patients undergoing endoscopic resection for esophageal neoplasms between October, 2010 and June, 2013 in our endoscopy center were analyzed retrospectively. According to the inclusion and exclusion criteria, 29 patients receiving ESTD or ESD for large esophageal superficial neoplasms were enrolled for data analysis.

RESULTS

Of the 29 patients, 11 underwent ESTD and 18 received ESD. The dissection speed of ESTD was significantly higher than that of ESD (22.4∓5.2 mm(2)/min vs 12.2∓4.0 mm(2)/min, P<0.05). Despite a similar en bloc rate between the two groups (100% [11/11] vs 88.9% [16/18], P>0.05), the radical curative rate of ESTD was significantly greater than that of ESD (81.8% [9/11] vs 66.7% [12/18], P<0.05). No serious bleeding or perforation occurred in the patients except for 1 in ESD group with intraoperative bleeding, which was managed with hemostatic forceps. Eight patients had postoperative esophageal strictures in relation with circumferential extension and the longitudinal length (P<0.05).

CONCLUSION

ESTD is a safe and effective alternative for large esophageal superficial neoplasms with a shortened operative time, a higher dissection speed and a higher radical curative rate in comparison with ESD, but postoperative esophageal strictures should be closely monitored especially for lesions more than 3/4 of the circumferential extension or exceeding 50 mm.

[Evaluation of the application of endoscopic submucosal dissction in gastrointestinal cysts]

OBJECTIVE

To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for the treatment of gastrointestinal cysts.

METHODS

Clinicopathological data of 40 patients with gastrointestinal cyst undergoing ESD in our center during January 2008 and February 2012 were analyzed retrospectively. Complications, en bloc resection rate, and local recurrence were assessed.

RESULTS

Eight lesions located in the esophagus, 11 in the stomach, 5 in the duodenum, and 16 in the colorectum. Thirty-seven lesions were successfully resected with ESD in an en bloc fashion (92.5%). During the operation, one perforation was encountered in the ascending colon and was clipped; one massive hemorrhage occurred in the esophagus and was treated with balloon compression. Postoperative pathological examination revealed cyst samples were intact without lesions in lateral and basal resection margins. Local recurrence was not found in 36 patients during a median postoperative follow-up of 9.7 months (range, 6-12 months).

CONCLUSION

ESD is a safe and effective procedure for the treatment of gastrointestinal cysts.

[Rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch in the treatment of congenital high anal atresia in the newborn]

OBJECTIVE

To explore the value of rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch in the treatment of congenital high anal atresia in the newborn.

METHODS

Clinical data of 232 newborns diagnosed as congenital high anal atresia undergoing operation from January 2001 to December 2010 were retrospectively analyzed. Among these patients, 168 underwent rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch through the previous of sagittal approach (intrathecal pull-through group), and 64 cases underwent the Pena procedure (Pena group). Patients were followed up for two years. Kelly score was used to estimate postoperative anorectal function. Defecography was used to examine the morphology of anorectum. Rectal pressure was measured as well.

RESULTS

Two years after operation, Kelly score revealed that 126 (75.0%) cases in the intrathecal pull-through group and 54 cases (84.4%) in the Pena group had good control defecation (P>0.05), while constipation rate was significantly lower in intrathecal pull-through group [8.3% (14/168) vs. 21.9% (14/64), P<0.05]. Postoperative barium defecography showed that defecation rectum maximum diameter was (2.2±0.3) cm in intrathecal pull-through group and (2.3±0.8) cm in the Pena group (P>0.05). Anorectal manometry showed rectal maximum capacity threshold value was (91.4±15.2) ml in the intrathecal pull-through group and (95.1±18.6) ml in the Pena group (P>0.05). There were no significant differences in defecography, anal bowel function and anorectal manometry between the two groups postoperatively (all P>0.05).

CONCLUSIONS

Rectal mucosa stripping and pull-through from rectal muscle sheath of blind pouch through the former sagittal can be completed with one-stage operation in newborn for the treatment of congenital high anal atresia, the efficacy of which is similar to the classic Pena operation. This procedure can avoid other operations, ameliorate the pains of newborns, decrease the burden of family, and has lower constipation rate, therefore it is a valid surgical option.

[Prevention and treatment of complications during and after endoscopic mucosal band ligation for esophageal precancerous lesions and early cancer]

OBJECTIVE

To investigate the prevention and treatment of complications during and after endoscopic mucosal band ligation (EMBL) for precancerous lesions and early cancer in the esophagus.

METHODS

Clinical data of 47 patients with esophageal precancerous lesions and early cancer undergoing EMBL in our center from June 2011 to August 2013 were reviewed retrospectively. Complications and associated treatment during operation, after operation and during follow-up were analyzed.

RESULTS

Complications during operation included 7 cases of bleeding (14.9%) and 1 case of perforation (2.1%), who received hot biopsy forceps and argon plasma coagulation to stop bleeding successfully, and titanium clamp to suture wound surface. No cutaneous emphysema and pneumothorax occurred. Complications after operation included 1 case of delayed bleeding (2.1%) who received blood stopping under gastroscope, 2 cases of mediastinal and subcutaneous emphysema (4.3%), 6 cases of pleural effusion (12.8%), and 5 cases of minor inflammation or segmental atelectasis of pulmonary (10.6%), who all received successful conservative treatment. Seven cases of esophageal stricture occurred during follow-up, who were improved by balloon dilatation and metal-film stent placement. No deaths associated with EMBL occurred. All the complications were cured through conservative treatment. No additional surgery associated with the complications was needed. Post-operative pathology revealed 1 case was chronic inflammatory hyperplasia, 11 were low-grade intraepithelial tumor, 15 were high-grade intraepithelial tumor, 8 were carcinoma in situ, 12 were squamous cancer (8 with invasion into mucous muscular layer, 4 into submucous layer). Only 1 case of submucous cancer needed transthorax esophageal cancer radical operation because of dangerous margin. No relapse case was found during followed-up.

CONCLUSION

EMBL can treat the esophageal precancerous lesions and early esophageal cancer effectively and its complications can be managed with conservative therapy usually.

A phase II study of endoscopic submucosal dissection for superficial esophageal neoplasms (KDOG 0901)

BACKGROUND

Most previous studies of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms were retrospective; prospective studies are scant.

OBJECTIVE

To prospectively assess the efficacy and safety of ESD for superficial esophageal neoplasms.

DESIGN

Phase II study.

SETTING

University hospital.

PATIENTS

Fifty-two patients (median age 68 years; 48 men) who had a histologic diagnosis of superficial esophageal cancer without metastasis on CT or high-grade intraepithelial neoplasia (HGIN) were enrolled from April 2009 through November 2011.

INTERVENTION

ESD was used to treat 56 lesions. All procedures were done by 4 endoscopists who each had previously performed ESD in more than 100 patients with gastric tumors.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was the R0 resection rate, and secondary endpoints were the safety and the rate of accurately diagnosing tumor depth on endoscopic examination.

RESULTS

The median treatment time was 69 minutes (24-168 minutes). The histopathologic diagnosis was squamous cell carcinoma in 49 lesions, HGIN in 5, and tubular adenocarcinoma in 2. The en bloc resection rate and R0 resection rate were 100% and 94.6%, respectively. The rates of adverse events during ESD and after ESD were 22.2% and 53.8%, respectively, but most events were mild. One patient (1.9%) had mediastinal emphysema without perforation. The rate of accurately diagnosing tumor depth on endoscopic examination was 76.8%.

LIMITATIONS

Single-center, nonrandomized study.

CONCLUSION

Our study showed that ESD was an effective and relatively safe treatment for superficial esophageal neoplasms. ESD may be a useful treatment option for superficial esophageal neoplasms in hospitals with endoscopists who are experts in performing ESD for gastric tumors. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000002047.).

Submucosal anoderm-preserving hemorrhoidectomy revisited: a modified technique for the surgical management of hemorrhoidal crisis

Submucosal hemorrhoidectomy (Parks' procedure) is a recognized method for treating acute hemorrhoidal crisis. Anoderm preservation has been stressed in various techniques described for elective or emergency excisional hemorrhoidal management. Mucopexy techniques have been proven useful as an adjunct to minimally resectional techniques. A modified submucosal technique with anoderm preservation and mucopexy was applied to 45 patients who presented on an emergency basis with hemorrhoidal crisis. External piles were minimally removed, the minimum possible amount of diseased mucosa was excised, a linear incision was used at the anoderm to enter the subanodermal/mucosal plane to achieve the submucosal excision, and a mucopexy was added at the approximation of the mucosal flaps. Postoperative morbidity was minimal and pain after the procedure remained at acceptable levels. This technique allows for an excision limited to the pathology with important anatomic tissue preservation. This results in conservation of the sensitive and useful anoderm, a decreased risk of stenosis, and addresses the mucosal prolapse. The level of postoperative pain with this technique is acceptable and long-term follow-up reveals a high degree of patient satisfaction.

Clonal selection and persistence in dysplastic Barrett's esophagus and intramucosal cancers after failed radiofrequency ablation

OBJECTIVES

Radiofrequency ablation (RFA) is used to successfully eliminate Barrett's esophagus (BE)-related dysplasia or intramucosal carcinoma and aims to cause reversion to squamous epithelium. However, in 20% of cases RFA fails to return the epithelium to squamous phenotype. Follow-up studies show a similar dysplasia recurrence rate. We hypothesize that failed RFA is due to clonally mutated epithelial populations harbored in RFA-privileged sites and that RFA can select for the mutant clonal expansion.

METHODS

A longitudinal case series of 19 patients with BE and high-grade dysplasia or intramucosal carcinoma were studied. DNA was extracted from individual Barrett's glands, deep esophageal glands within mucosal resections and biopsy specimens before and after RFA. Mutations were identified by targeted sequencing of genes commonly mutated in Barrett's adenocarcinoma.

RESULTS

Five patients demonstrated persistent post-RFA pathology with persistent mutations, sometimes detected in deep esophageal glands or neighboring squamous epithelium after several rounds of RFA preceded by mucosal resection. Recurrence of pathology in three other patients was characterized by de novo mutations.

CONCLUSIONS

Protumorigenic mutations can be found in post-ablation squamous mucosa as well as in mutant deep esophageal glands; both are associated with dysplasia recurrence. Following RFA, non-dysplastic Barrett's epithelium can contain mutant clones that are found in a subsequent adenocarcinoma. Ablation may also drive the clonal expansion of pre-existing clones after a "bottleneck" created by the RFA. Overall, recurrence of dysplasia post RFA reflects the multicentric origins of Barrett's clones and highlights the role of clonal selection in carcinogenesis.

Radical excision of Barrett's esophagus and complete recovery of normal squamous epithelium

To treat Barrett’s esophagus (BE), radiofrequency ablation or cryotherapy are effective treatments for eradicating BE with dysplasia and intestinal metaplasia, and reduce the rates of Barrett’s esophageal adenocarcinoma (BAC). However, patients with BE and dysplasia or early cancer who achieved complete eradication of intestinal metaplasia, BE recurred in 5% within a year, requiring expensive endoscopic surveillances. We performed endoscopic submucosal dissection as complete radically curable treatment procedure for BE with dysplasia, intestinal metaplasia and BAC.

[Preliminary exploration on submucosal tunneling endoscopic resection for middle and lower esophagus submucosal tumors]

OBJECTIVE

To evaluate the efficacy and safety of submucosal tunneling endoscopic resection (STER) in the treatment of middle and lower esophagus submucosal tumors (SMT) originating from muscularis propria (MP) layer.

METHODS

A total number of 33 esophagus submucosal tumor (SMT) originating from MP layer underwent tumor resection by STER after endoscopic ultrasonography (EUS) and CT examination at Endoscopy Center, Department of Gastroenterology, First Affiliated Hospital, Nanjing Medical University from March 2012 to March 2013. There were 17 males and 16 females with an age range of (50 ± 10) years. Their lesion size, lesion origin, pathology, operative duration and complication rate were analyzed.

RESULTS

Among them, the origins were of submucosal (n = 4, 12.1%), superficial muscularis propria layer (SMP) (n = 18, 54.6%), deep muscularis layer (DMP) (n = 10, 30.3%) and serosa (n = 1, 3.0%). There were single tumor (n = 30, 90.9%), double tumors (n = 2, 6.1%) and triple tumors (n = 1, 3.0%). Except for 1 case of non-resected hemangioma, 36 operative specimens were examined pathologically, including 30 leiomyomas tumors (83.3%), 5 stromal tumors (GIST) (13.9%) and 1 lipoma tumor (2.8%). Thirty-two lesions were successfully resected by STER with a complete resection rate of 97.0%. Average lesion size was (1.7 ± 1.0) cm and average operative duration (49 ± 26) min. A number of (7.8 ± 2.5) hemostatic clips were used to close the mucosal incision site. Subcutaneous emphysema occurred in 3 patients (9.1%) while puncture and pneumothorax developed in one case (3.0%). All of them recovered uneventfully through conservative treatments.

CONCLUSIONS

As a new safe, efficacious and feasible treatment for middle and lower esophagus submucosal tumors, STER may completely resect SMT and provide accurate histopathological evaluations. And it is feasible to regain the mucosal integrity of GI tract and prevent the occurrences of leakage and secondary infections.

[Effect of ladder ring suture of esophageal mucosa vascular combined with Nissen' s fundoplication on prevention from rebleeding of patients with advanced schistosomiasis]

OBJECTIVE

To evaluate the effectiveness of the ladder ring suture of the esophageal mucosa vascular combined with Nissen's fundoplication on provention from rebleeding of patients with advaced schistosomiasis

METHODS

From August 2006 to August 2011, 75 patients with advanced schistosomiasis portal hypertension received the portal azygous disconnection and ladder ring suture of the esophageal mucosa vascular combined with Nissen's fundoplication (a combined group), and 83 patients with advanced schistosomiasis portal hypertension received the portal azygous disconnection only (a simple group), and the results of the follow-up were analyzed.

RESULTS

The effective rates were 81.3% (61/75) in the combined group and 30.1% (25/83) in the simple grouup, and the rebleeding rates were 2.7% (2/75) and 12.0% (10/83) in the two groups, respectively (P < 0.01).

CONCLUSION

The ladder ring suture of the esophageal mucosa vascular combined with Nissen' s fundoplication is effective and safe on the prevention from rebleeding of patients with advaced schistosomiasis.