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50 Endoscopic Submucosal Dissection for Superficial Colorectal Tumors With Extension Into the Appendiceal Orifice
Abstracts 1
Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan; 2Department of Neuropathology, Brain Bank for Aging Research, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan; 3Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
Fig.2. Kaplan-Meier cumulative recurrence rates. En bloc resections with free vertical margin and no risk factors for lymph node metastasis (nZ 44): LM0 (nZ 23) vs. LM1/LMx (nZ 21). 50 Endoscopic Submucosal Dissection for Superficial Colorectal Tumors With Extension Into the Appendiceal Orifice Kazuki Boda*1, Shinji Tanaka1, Shiro Oka2, Ken Yamashita2, Kyoku Sumimoto2, Daiki Hirano2, Yuzuru Tamaru2, Yuki Ninomiya2, Kenjiro Shigita2, Nana Hayashi1, Kazuaki Chayama2 1 Endoscopy, Hiroshima University Hospital, Hiroshima, Japan; 2 Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan Background: Endoscopic submucosal dissection (ESD) has been described as a reliable method for the treatment of superficial colorectal tumors. However, there are few reports regarding the use of ESD for cecal tumors presenting with extension into the appendiceal orifice. Herein, we assessed the feasibility and safety of ESD for cecal tumors with extension into the appendiceal orifice. Patients and Methods: We retrospectively examined the outcomes of ESD for 78 consecutive patients with 78 cecal tumors (male/female ratio, 40/48; mean age, 67 years old; average tumor size, 3215 mm; with the following lesions: adenoma [31 lesions], Tis carcinoma [29 lesions], and T1 carcinoma [16 lesions]), who underwent ESD at the Hiroshima University Hospital from October 2008 to March 2016. The indication for ESD in cecal tumors with extension into the appendiceal orifice is to be able to recognized the distal edge of the lesion in appendix. They were classified into two groups: patients with cecal tumors extending into the appendiceal orifice (Group A: 29 patients, 29 tumors) and patients with cecal tumors that did not extend into the appendiceal orifice (Group B: 49 patients, 49 tumors). We compared the outcomes of ESD between the two groups. Results: No significant differences in clinicopathological characteristics were observed between the two groups. The average procedure time in Group A was 117127 minutes, while in Group B was 8252 minutes. The rate of severe submucosal fibrosis in Group A (48%) was significantly higher than that in Group B (24%) (p<0.05). The average procedure speed in Group A (1410 mm2/min) was significantly slower than that in Group B (2316 mm2/min) (p<0.01). The en bloc resection rate in Group A was 90% compared with 96% in Group B, and the histological complete resection rates were 86% and 88% in Group A and Group B, respectively. Perforation during the procedure occurred in 2 (6%) patients in Group A and in 1 (2%) patients in Group B. Delayed bleeding occurred in 1 (3%) patient in Group A and in 2 (4%) patients in Group B. None of the patients required surgery. There were no significant differences in adverse events reported between the two groups. Conclusion: ESD for cecal tumors with extension into the appendiceal orifice is effective and safe.
51 Enteric Nervous System Visualization of Hirschsprung’s Disease Using Confocal Laser Endomicroscopy: Ex Vivo Human Trial Masakuni Kobayashi*1, Naoki Shimojima3, Shunsuke Kamba1, Junko Takahashi-Fujigasaki2, Kazuki Sumiyama1
AB44 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Background: In the operation for Hirschsprung’s disease, an intraoperative pathological diagnosis is necessary to assess the extent of abnormal area of the enteric nervous system (ENS) (aganglionic area). ENS stretches throughout the gastrointestinal tract in a network pattern; therefore, the intraoperative pathological diagnosis evaluating only a small isolated area, is not appropriate to identify the aganglionic area during the surgery. We have reported that the technical feasibility of visualizing ENS in intestines with the combined use topically application Cresyel Violet (CV) and a confocal laser endomicroscopy (CLE). The aim of this study was to evaluate the technical feasibility of visualization of ENS with CLE in Hirschsprung’s disease and also comparing the morphology finding of ENS with that of control cases. Method: We enrolled patients who underwent intestinal resections for the treatment of Hirschsprung’s disease or other gastrointestinal diseases, such as imperforate anus, Meckel’s diverticulum, jejunal atresia. The CLE system used in the current study was probe-based CLE (pCLE: Cellvizio system, Mauna Kea Technologies, Paris, France). First, a tip of the probe was gently applied on to a serosal side of the specimen after the topical application of 0.1% CV and then the CLE scanning was performed to a 100-mm2 surface area at the center of each specimen by a manually probe control. All examined specimens stained with hematoxylin and eosin were pathologically evaluated with horizontally sliced sections. The accuracy of visualization of ENS using CLE was evaluated using the pathological presence/absence of ENS as the gold standard. In positive cases showing ENS with CLE, mean maximum widths of nerve strands visualized by CLE were measured in the Cellvizio Viewer images (Mauna Kea Technologies, Paris, France). Results: 20 patients (71 specimens) were enrolled in the study. In the overall cases, the accuracy, sensitivity and specificity of visualization of ENS were 90.1%, 91.2% and 89.2%, respectively. The accuracy of visualization of ENS was 89.5% for 9 Hirschsprung’s disease cases (57 specimens) and 92.9% for 11 control cases (14 specimens), respectively. The maximum average width of nerve strands of Hirschsprung’s disease cases was significantly shorter than that of control cases (35.0mm vs 70.5mm, P Z .03). Conclusion: Results of this study demonstrated that the microscopic deformity of ENS in Hirschsprung’s disease could be clearly visualized with CLE in real-time.
52 Post-ERCP Pancreatitis in Children and a Report Form an International Multicenter Study Group (Pedi Database) David M. Troendle*1,2, Bradley Barth1,2, Douglas S. Fishman3,4, Quin Liu5, Yuhua Zheng6,7, Matthew J. Giefer8,9, Kyung M. Kim10,11, Luigi Dall’Oglio12, Giulia Angelino12, Paola De Angelis12, Simona Faraci12, Mercedes Martinez13,14, Roberto Gugig15, Petar Mamula16, Samuel Bitton17,18, Michael Wilsey19, Racha T. Khalaf19, Steven Werlin20,21, Kulwinder S. Dua20,21, Amit S. Grover22,23, Victor L. Fox22,23 1 UT Southwestern Medical Center, Dallas, TX; 2Children’s Health Children’s Medical Center, Dallas, TX; 3Baylor College of Medicine, Houston, TX; 4Texas Children’s Hospital, Houston, TX; 5Cedars-Sinai Medical Center, Los Angeles, TX; 6University of Southern California, Los Angeles, CA; 7Children’s Hospital of Los Angeles, Los Angeles, CA; 8 University of Washington, Seattle, WA; 9Seattle Children’s Hospital, Seattle, WA; 10University of Ulsan College of Medicine, Seoul, Korea (the Republic of); 11Asan Medical Center Children’s Hospital, Seoul, Korea (the Republic of); 12Bambino Gesu Children’s Hospital, Rome, Italy; 13 Columbia University, New York, NY; 14New York Presbyterian Morgan Stanley Children’s Hospital of New York, New York, NY; 15Children’s Hospital of Central California, Madera, CA; 16Children’s Hospital of Philadelphia, Philadelphia, PA; 17Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY; 18Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, NY; 19Johns Hopkins All Children’s Hospital, St. Petersburg, FL; 20Medical College of Wisconsin, Milwaukee, WI; 21Children’s Hospital of Wisconsin, Milwaukee, WI; 22 Harvard Medical School, Boston, MI; 23Boston Children’s Hospital, Boston, MA Introduction: Risk factors for development of post-ERCP pancreatitis (PEP) remain poorly defined in the pediatric patients. It remains unclear what constitutes appropriate prophylaxis (PPx) in this patient population to prevent PEP. Aim: To identify factors associated with PEP in the pediatric population, and evaluate utility PEP PPx utilizing a prospective multicenter approach. Methods: Consecutive ERCPs on children < 19 years from 13 IRB approved centers were entered into a REDCap database. Inclusion criteria for analysis included: ERCPs entered between 5/1/2014 to 11/29/2016 and pre-procedural form completed prospectively (before ERCP performed). Fischer’s exact test was utilized to evaluate association of pre-procedural and procedural factors with development of PEP as well as effectiveness of PEP PPx. High risk patients were defined as those with PD injection. PEP and its severity was defined according to the ASGE lexicon. Results: 707 ERCPs in 549 (78%) unique
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Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan; 2Department of Neuropathology, Brain Bank for Aging Research, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan; 3Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
Fig.2. Kaplan-Meier cumulative recurrence rates. En bloc resections with free vertical margin and no risk factors for lymph node metastasis (nZ 44): LM0 (nZ 23) vs. LM1/LMx (nZ 21). 50 Endoscopic Submucosal Dissection for Superficial Colorectal Tumors With Extension Into the Appendiceal Orifice Kazuki Boda*1, Shinji Tanaka1, Shiro Oka2, Ken Yamashita2, Kyoku Sumimoto2, Daiki Hirano2, Yuzuru Tamaru2, Yuki Ninomiya2, Kenjiro Shigita2, Nana Hayashi1, Kazuaki Chayama2 1 Endoscopy, Hiroshima University Hospital, Hiroshima, Japan; 2 Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan Background: Endoscopic submucosal dissection (ESD) has been described as a reliable method for the treatment of superficial colorectal tumors. However, there are few reports regarding the use of ESD for cecal tumors presenting with extension into the appendiceal orifice. Herein, we assessed the feasibility and safety of ESD for cecal tumors with extension into the appendiceal orifice. Patients and Methods: We retrospectively examined the outcomes of ESD for 78 consecutive patients with 78 cecal tumors (male/female ratio, 40/48; mean age, 67 years old; average tumor size, 3215 mm; with the following lesions: adenoma [31 lesions], Tis carcinoma [29 lesions], and T1 carcinoma [16 lesions]), who underwent ESD at the Hiroshima University Hospital from October 2008 to March 2016. The indication for ESD in cecal tumors with extension into the appendiceal orifice is to be able to recognized the distal edge of the lesion in appendix. They were classified into two groups: patients with cecal tumors extending into the appendiceal orifice (Group A: 29 patients, 29 tumors) and patients with cecal tumors that did not extend into the appendiceal orifice (Group B: 49 patients, 49 tumors). We compared the outcomes of ESD between the two groups. Results: No significant differences in clinicopathological characteristics were observed between the two groups. The average procedure time in Group A was 117127 minutes, while in Group B was 8252 minutes. The rate of severe submucosal fibrosis in Group A (48%) was significantly higher than that in Group B (24%) (p<0.05). The average procedure speed in Group A (1410 mm2/min) was significantly slower than that in Group B (2316 mm2/min) (p<0.01). The en bloc resection rate in Group A was 90% compared with 96% in Group B, and the histological complete resection rates were 86% and 88% in Group A and Group B, respectively. Perforation during the procedure occurred in 2 (6%) patients in Group A and in 1 (2%) patients in Group B. Delayed bleeding occurred in 1 (3%) patient in Group A and in 2 (4%) patients in Group B. None of the patients required surgery. There were no significant differences in adverse events reported between the two groups. Conclusion: ESD for cecal tumors with extension into the appendiceal orifice is effective and safe.
51 Enteric Nervous System Visualization of Hirschsprung’s Disease Using Confocal Laser Endomicroscopy: Ex Vivo Human Trial Masakuni Kobayashi*1, Naoki Shimojima3, Shunsuke Kamba1, Junko Takahashi-Fujigasaki2, Kazuki Sumiyama1
AB44 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Background: In the operation for Hirschsprung’s disease, an intraoperative pathological diagnosis is necessary to assess the extent of abnormal area of the enteric nervous system (ENS) (aganglionic area). ENS stretches throughout the gastrointestinal tract in a network pattern; therefore, the intraoperative pathological diagnosis evaluating only a small isolated area, is not appropriate to identify the aganglionic area during the surgery. We have reported that the technical feasibility of visualizing ENS in intestines with the combined use topically application Cresyel Violet (CV) and a confocal laser endomicroscopy (CLE). The aim of this study was to evaluate the technical feasibility of visualization of ENS with CLE in Hirschsprung’s disease and also comparing the morphology finding of ENS with that of control cases. Method: We enrolled patients who underwent intestinal resections for the treatment of Hirschsprung’s disease or other gastrointestinal diseases, such as imperforate anus, Meckel’s diverticulum, jejunal atresia. The CLE system used in the current study was probe-based CLE (pCLE: Cellvizio system, Mauna Kea Technologies, Paris, France). First, a tip of the probe was gently applied on to a serosal side of the specimen after the topical application of 0.1% CV and then the CLE scanning was performed to a 100-mm2 surface area at the center of each specimen by a manually probe control. All examined specimens stained with hematoxylin and eosin were pathologically evaluated with horizontally sliced sections. The accuracy of visualization of ENS using CLE was evaluated using the pathological presence/absence of ENS as the gold standard. In positive cases showing ENS with CLE, mean maximum widths of nerve strands visualized by CLE were measured in the Cellvizio Viewer images (Mauna Kea Technologies, Paris, France). Results: 20 patients (71 specimens) were enrolled in the study. In the overall cases, the accuracy, sensitivity and specificity of visualization of ENS were 90.1%, 91.2% and 89.2%, respectively. The accuracy of visualization of ENS was 89.5% for 9 Hirschsprung’s disease cases (57 specimens) and 92.9% for 11 control cases (14 specimens), respectively. The maximum average width of nerve strands of Hirschsprung’s disease cases was significantly shorter than that of control cases (35.0mm vs 70.5mm, P Z .03). Conclusion: Results of this study demonstrated that the microscopic deformity of ENS in Hirschsprung’s disease could be clearly visualized with CLE in real-time.
52 Post-ERCP Pancreatitis in Children and a Report Form an International Multicenter Study Group (Pedi Database) David M. Troendle*1,2, Bradley Barth1,2, Douglas S. Fishman3,4, Quin Liu5, Yuhua Zheng6,7, Matthew J. Giefer8,9, Kyung M. Kim10,11, Luigi Dall’Oglio12, Giulia Angelino12, Paola De Angelis12, Simona Faraci12, Mercedes Martinez13,14, Roberto Gugig15, Petar Mamula16, Samuel Bitton17,18, Michael Wilsey19, Racha T. Khalaf19, Steven Werlin20,21, Kulwinder S. Dua20,21, Amit S. Grover22,23, Victor L. Fox22,23 1 UT Southwestern Medical Center, Dallas, TX; 2Children’s Health Children’s Medical Center, Dallas, TX; 3Baylor College of Medicine, Houston, TX; 4Texas Children’s Hospital, Houston, TX; 5Cedars-Sinai Medical Center, Los Angeles, TX; 6University of Southern California, Los Angeles, CA; 7Children’s Hospital of Los Angeles, Los Angeles, CA; 8 University of Washington, Seattle, WA; 9Seattle Children’s Hospital, Seattle, WA; 10University of Ulsan College of Medicine, Seoul, Korea (the Republic of); 11Asan Medical Center Children’s Hospital, Seoul, Korea (the Republic of); 12Bambino Gesu Children’s Hospital, Rome, Italy; 13 Columbia University, New York, NY; 14New York Presbyterian Morgan Stanley Children’s Hospital of New York, New York, NY; 15Children’s Hospital of Central California, Madera, CA; 16Children’s Hospital of Philadelphia, Philadelphia, PA; 17Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY; 18Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, NY; 19Johns Hopkins All Children’s Hospital, St. Petersburg, FL; 20Medical College of Wisconsin, Milwaukee, WI; 21Children’s Hospital of Wisconsin, Milwaukee, WI; 22 Harvard Medical School, Boston, MI; 23Boston Children’s Hospital, Boston, MA Introduction: Risk factors for development of post-ERCP pancreatitis (PEP) remain poorly defined in the pediatric patients. It remains unclear what constitutes appropriate prophylaxis (PPx) in this patient population to prevent PEP. Aim: To identify factors associated with PEP in the pediatric population, and evaluate utility PEP PPx utilizing a prospective multicenter approach. Methods: Consecutive ERCPs on children < 19 years from 13 IRB approved centers were entered into a REDCap database. Inclusion criteria for analysis included: ERCPs entered between 5/1/2014 to 11/29/2016 and pre-procedural form completed prospectively (before ERCP performed). Fischer’s exact test was utilized to evaluate association of pre-procedural and procedural factors with development of PEP as well as effectiveness of PEP PPx. High risk patients were defined as those with PD injection. PEP and its severity was defined according to the ASGE lexicon. Results: 707 ERCPs in 549 (78%) unique
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