- Email: [email protected]
A New Device to Simplify Flexible Endoscopic Treatment of Zenker'S Diverticulum
Abstracts
T1460 Closure of Luminal Defects Using Endoscopic Clips and Detachable Snares Kyung W. Noh, Timothy A. Woodward Background: Complications of endoscopic mucosal resection (EMR) include perforations and the formation of large mucosal defects. Recently, the use of endoscopic clipping devices to close iatrogenic perforations has been demonstrated. We describe a novel method of closure using a combination of endoscopic clips and detachable snares. Methods: Patients undergoing EMR with resultant large mucosal defects underwent closure using this technique. Endoscopic clips were placed on either edges of the defect at 5 mm intervals and detachable snares were deployed around the base of each opposing endoclips and closed. (Figure 1) Results: Two patients had closure of mucosal defects using this technique. Patient 1 underwent EMR of a 3 cm submucosal lesion of the stomach using standard techniques. No obvious perforation was seen but given the size of the defect, a decision was made to close the defect. Patient 2 was found to have a 3 by 6 cm rectal polyp. Biopsies revealed carcinoma-in-situ. As the patient was considered a poor surgical candidate, EMR was performed. No obvious perforation was observed, but the resulting large mucosal defect was closed. Both patients were discharged from the GI unit after standard observation. Discussion: Endoscopic clipping devices have been used to close mucosal defects and perforations caused by EMR. In the cases of larger defects, the use of clips alone to close the defect may be technically difficult. We describe a novel technique in which detachable snare devices are used in conjunction with endoscopic clips placed on either edges of the mucosal defect for closure. Both patients were dismissed from the endoscopy suite after standard post procedure observation. We believe that closure of large defects will lead to faster mucosal healing. This is an additional technique to manage complications of EMR.
T1461 Clinical Outcome of Endoscopic Treatment for Early Gastric Cancer Jong-Soo Lee, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee, Tae-Sung Sohn, Jae Hung Noh, Sung Kim, Cheol Keun Park Background: Endoscopic mucosal resection (EMR) has become a good option for the treatment of selected cases with early gastric cancer (EGC). However, data on the results of long-term follow after EMR for EGC are limited, and appropriate strategy for non-curative resection is still controversial. The purpose of this study was to evaluate the clinical outcome of EMR for EGC. Methods: We retrospectively analyzed 283 patients with EGC treated by EMR at Samsung Medical Center from January 2000 to June 2005. Median age of the patients was 64 years (range 26-85). The male to female ratio was 3.22:1 (216:67). The methods of EMR were mainly snare resection after circumferential precutting (EMR-P, n Z 162) and endoscopic submucosal dissection (ESD, n Z 91). The criteria for curative resection were en bloc resection or complete resection in piecemeal resection, well to moderate differentiated histology, free of tumor in resected margin, intramucosal lesion, and no vascular or lymphatic invasion. Additional treatments, usually surgery, were recommended for cases with non-curative or non-evaluable results. The median duration of follow up was 21 months (range 3-66 months). Results: The mean size of cancerous lesion was 1.38 G 0.75 cm. The overall rate of curative resection was 72.1 %. The rate of curative resection was highest with ESD (80.2%), followed by
AB232 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
EMR-P (70.3%). Submucosal invasion was found in 44 cases (15.5%). In patients with curative resection, local recurrence at EMR site was found in only one case (0.5%). In 51 cases, which underwent surgical resection due to non-curative or nonevaluable resection, residual cancer was found in 13 cases (25.0%). Among 28 patients, who were followed up without surgery after non-curative or non-evaluable results, there were 13 recurrences (12 local recurrences and 1 hepatic metastasis) after a median follow-up of 7 months. Five patients died during the follow up period, but there was no death related to gastric cancer. Conclusions: The rate of local recurrence was 0.5% after curative resection and metachronous recurrence rate was 2.2%. EMR is an effective treatment method for adequate indicated patients with early gastric cancer, however, close observation was very important.
T1462 A New Device to Simplify Flexible Endoscopic Treatment of Zenker’S Diverticulum Diahann L. Seaman, Christopher Gostout, Elizabeth Rajan, Mary Knipschield Background: Enodscopic treatment of Zenker’s Diverticulum (ZD) is preferred with less morbidity and more simplicity than open surgical procedures. Electrocautery is used to divide the septum using a nasogastric tube for guidance. Maintaining a stable position and clear visualization challenges the procedure. To overcome this problem techniques utilizing an oblique transparent cap or an overtube have been used with limited success. We have observed the porcine hypopharyngeal pouch to be very similar in appearance to a ZD. While passing the widespread endoscopic mucosal resection device (WEMR) into the esophagus we realized that its shape was perfectly suited to stabilize and cut the septum dividing the porcine hypopharyngeal pouch from the esophagus in a similar manner as with a ZD. Aim: To prospectively use the WEMR cap device to incise the hypopharyngeal pouch septum. Methods: Six female domestic pigs were used. A diagnostic gastroscope (GIF 130; Olympus America, Mellville, NY) was used with the prototype WEMR cap (1980 character figures 1 and 2 to be shown if accepted). The built-in cutting wire was used to incise the hypopharyngeal-esophageal septum. Three pigs were sacrificed immediately after the procedure and dissection of the area was performed to exclude perforation. The remaining pigs were survived for three weeks. A barium swallow was performed in one survived pig. The remaining pigs were sacrificed and an excisional neck dissection was performed. Results: The procedure was technically easy. Average procedure time was 10 minutes. Limited bleeding occurred in the first pig using 20 watts of cutting current. In the remaining pigs, blended current was used. The cut could be extended as far down the septum as possible with the cap working as a stopper. After cutting, the septum disappeared almost completely. No overt complications occurred. Endoscopy in the survived pigs showed a very small residual septum with an anteroposterior scar. The barium swallow revealed no pouch and mild angulation. Barium easily passed into the esophageal lumen. Discussion: The WEMR cap can be used to incise the septum in an animal model simulating ZD. The use of this device has advantages of maintaining stable position throughout the procedure; avoiding accidental perforation from the protective cap rim that impedes further advancement once the cap edge reaches the bottom of the pouch. This device facilitates the procedure and may popularize this procedure among gastrointestinal endoscopists.
T1463 Effect of Oral Proton Pump Inhibitor On Delayed Bleeding After Endoscopic Mucosal Resection Dae Young Jeong, Soo-Heon Park, Tae Ho Kim, Hyun Jong Oh, Jin Il Kim, Se-Hyun Cho, Joon Yeol Han, Jae Kwang Kim, Kyu-Yong Choi, in-Sik Chung Background: Endoscopic mucosal resection is indicated for the treatment of superficial type early gastric cancer and adenoma. Bleeding can occur during the procedure or be delayed after the procedure. The efficacy of acid suppression on prevention of EMR induced bleeding is unexplored. The aim of this study was to evaluate the efficacy of oral rabeprazole and intravenous ranitidine on prevention of bleeding after EMR. Methods: Fifty nine patients were enrolled after EMR. Proton pump inhibitor group had rabeprazole 20 mg b.i.d. via oral route. H2RA group had continuous intravenous administration of ranitidine 300 mg per day after EMR. Intragastric pH monitoring was done after 24 hours of EMR. Second look endoscopy was performed 48 hours after EMR. Results: The age, sex, EMR induced ulcer size and Helicobacter pylori infection rates were not different between the two groups. The median intragastric pH was significantly higher in PPI group than H2RA, 5.9 and 4.7, respectively (P Z 0.019). Delayed bleeding was defined as Forrest classification I during 2nd look endoscopy, hematemesis, tarry stool, hypotention, tachycardia and Hemoglobin level decrement more than 1 g/dL compared to baseline value after EMR. Delayed bleeding occurred significantly higher in H2RA group than PPI group, 8/33 (24.2%) and 1/26 (3.8%) respectively (P Z 0.031). Patients with delayed bleeding revealed significantly lower median intragastric than that of non-bleeding group, 3.9 and 5.6, respectively (P Z 0.014). Conclusion: Proton pump inhibitor decreased the risk of EMR induced bleeding more significantly than H2RA with profound intragastric acid suppression.
www.giejournal.org
T1460 Closure of Luminal Defects Using Endoscopic Clips and Detachable Snares Kyung W. Noh, Timothy A. Woodward Background: Complications of endoscopic mucosal resection (EMR) include perforations and the formation of large mucosal defects. Recently, the use of endoscopic clipping devices to close iatrogenic perforations has been demonstrated. We describe a novel method of closure using a combination of endoscopic clips and detachable snares. Methods: Patients undergoing EMR with resultant large mucosal defects underwent closure using this technique. Endoscopic clips were placed on either edges of the defect at 5 mm intervals and detachable snares were deployed around the base of each opposing endoclips and closed. (Figure 1) Results: Two patients had closure of mucosal defects using this technique. Patient 1 underwent EMR of a 3 cm submucosal lesion of the stomach using standard techniques. No obvious perforation was seen but given the size of the defect, a decision was made to close the defect. Patient 2 was found to have a 3 by 6 cm rectal polyp. Biopsies revealed carcinoma-in-situ. As the patient was considered a poor surgical candidate, EMR was performed. No obvious perforation was observed, but the resulting large mucosal defect was closed. Both patients were discharged from the GI unit after standard observation. Discussion: Endoscopic clipping devices have been used to close mucosal defects and perforations caused by EMR. In the cases of larger defects, the use of clips alone to close the defect may be technically difficult. We describe a novel technique in which detachable snare devices are used in conjunction with endoscopic clips placed on either edges of the mucosal defect for closure. Both patients were dismissed from the endoscopy suite after standard post procedure observation. We believe that closure of large defects will lead to faster mucosal healing. This is an additional technique to manage complications of EMR.
T1461 Clinical Outcome of Endoscopic Treatment for Early Gastric Cancer Jong-Soo Lee, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee, Tae-Sung Sohn, Jae Hung Noh, Sung Kim, Cheol Keun Park Background: Endoscopic mucosal resection (EMR) has become a good option for the treatment of selected cases with early gastric cancer (EGC). However, data on the results of long-term follow after EMR for EGC are limited, and appropriate strategy for non-curative resection is still controversial. The purpose of this study was to evaluate the clinical outcome of EMR for EGC. Methods: We retrospectively analyzed 283 patients with EGC treated by EMR at Samsung Medical Center from January 2000 to June 2005. Median age of the patients was 64 years (range 26-85). The male to female ratio was 3.22:1 (216:67). The methods of EMR were mainly snare resection after circumferential precutting (EMR-P, n Z 162) and endoscopic submucosal dissection (ESD, n Z 91). The criteria for curative resection were en bloc resection or complete resection in piecemeal resection, well to moderate differentiated histology, free of tumor in resected margin, intramucosal lesion, and no vascular or lymphatic invasion. Additional treatments, usually surgery, were recommended for cases with non-curative or non-evaluable results. The median duration of follow up was 21 months (range 3-66 months). Results: The mean size of cancerous lesion was 1.38 G 0.75 cm. The overall rate of curative resection was 72.1 %. The rate of curative resection was highest with ESD (80.2%), followed by
AB232 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
EMR-P (70.3%). Submucosal invasion was found in 44 cases (15.5%). In patients with curative resection, local recurrence at EMR site was found in only one case (0.5%). In 51 cases, which underwent surgical resection due to non-curative or nonevaluable resection, residual cancer was found in 13 cases (25.0%). Among 28 patients, who were followed up without surgery after non-curative or non-evaluable results, there were 13 recurrences (12 local recurrences and 1 hepatic metastasis) after a median follow-up of 7 months. Five patients died during the follow up period, but there was no death related to gastric cancer. Conclusions: The rate of local recurrence was 0.5% after curative resection and metachronous recurrence rate was 2.2%. EMR is an effective treatment method for adequate indicated patients with early gastric cancer, however, close observation was very important.
T1462 A New Device to Simplify Flexible Endoscopic Treatment of Zenker’S Diverticulum Diahann L. Seaman, Christopher Gostout, Elizabeth Rajan, Mary Knipschield Background: Enodscopic treatment of Zenker’s Diverticulum (ZD) is preferred with less morbidity and more simplicity than open surgical procedures. Electrocautery is used to divide the septum using a nasogastric tube for guidance. Maintaining a stable position and clear visualization challenges the procedure. To overcome this problem techniques utilizing an oblique transparent cap or an overtube have been used with limited success. We have observed the porcine hypopharyngeal pouch to be very similar in appearance to a ZD. While passing the widespread endoscopic mucosal resection device (WEMR) into the esophagus we realized that its shape was perfectly suited to stabilize and cut the septum dividing the porcine hypopharyngeal pouch from the esophagus in a similar manner as with a ZD. Aim: To prospectively use the WEMR cap device to incise the hypopharyngeal pouch septum. Methods: Six female domestic pigs were used. A diagnostic gastroscope (GIF 130; Olympus America, Mellville, NY) was used with the prototype WEMR cap (1980 character figures 1 and 2 to be shown if accepted). The built-in cutting wire was used to incise the hypopharyngeal-esophageal septum. Three pigs were sacrificed immediately after the procedure and dissection of the area was performed to exclude perforation. The remaining pigs were survived for three weeks. A barium swallow was performed in one survived pig. The remaining pigs were sacrificed and an excisional neck dissection was performed. Results: The procedure was technically easy. Average procedure time was 10 minutes. Limited bleeding occurred in the first pig using 20 watts of cutting current. In the remaining pigs, blended current was used. The cut could be extended as far down the septum as possible with the cap working as a stopper. After cutting, the septum disappeared almost completely. No overt complications occurred. Endoscopy in the survived pigs showed a very small residual septum with an anteroposterior scar. The barium swallow revealed no pouch and mild angulation. Barium easily passed into the esophageal lumen. Discussion: The WEMR cap can be used to incise the septum in an animal model simulating ZD. The use of this device has advantages of maintaining stable position throughout the procedure; avoiding accidental perforation from the protective cap rim that impedes further advancement once the cap edge reaches the bottom of the pouch. This device facilitates the procedure and may popularize this procedure among gastrointestinal endoscopists.
T1463 Effect of Oral Proton Pump Inhibitor On Delayed Bleeding After Endoscopic Mucosal Resection Dae Young Jeong, Soo-Heon Park, Tae Ho Kim, Hyun Jong Oh, Jin Il Kim, Se-Hyun Cho, Joon Yeol Han, Jae Kwang Kim, Kyu-Yong Choi, in-Sik Chung Background: Endoscopic mucosal resection is indicated for the treatment of superficial type early gastric cancer and adenoma. Bleeding can occur during the procedure or be delayed after the procedure. The efficacy of acid suppression on prevention of EMR induced bleeding is unexplored. The aim of this study was to evaluate the efficacy of oral rabeprazole and intravenous ranitidine on prevention of bleeding after EMR. Methods: Fifty nine patients were enrolled after EMR. Proton pump inhibitor group had rabeprazole 20 mg b.i.d. via oral route. H2RA group had continuous intravenous administration of ranitidine 300 mg per day after EMR. Intragastric pH monitoring was done after 24 hours of EMR. Second look endoscopy was performed 48 hours after EMR. Results: The age, sex, EMR induced ulcer size and Helicobacter pylori infection rates were not different between the two groups. The median intragastric pH was significantly higher in PPI group than H2RA, 5.9 and 4.7, respectively (P Z 0.019). Delayed bleeding was defined as Forrest classification I during 2nd look endoscopy, hematemesis, tarry stool, hypotention, tachycardia and Hemoglobin level decrement more than 1 g/dL compared to baseline value after EMR. Delayed bleeding occurred significantly higher in H2RA group than PPI group, 8/33 (24.2%) and 1/26 (3.8%) respectively (P Z 0.031). Patients with delayed bleeding revealed significantly lower median intragastric than that of non-bleeding group, 3.9 and 5.6, respectively (P Z 0.014). Conclusion: Proton pump inhibitor decreased the risk of EMR induced bleeding more significantly than H2RA with profound intragastric acid suppression.
www.giejournal.org